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THE OUTBREAK AT POCOMOKE CITY. The outbreak at Pocomoke City was, at the time of its discovery, somewhat threatening. The story of the outbreak is told in the report of Dr. C. F. Hargis among the reports of local health officers. It is only necessary here to give due credit to that officer for effective work.

When the first case was discovered the town was without a health officer. The Mayor being notified at once assembled the town council, appointed a health officer and notified the State Board of Health. The County Commissioners also assembled promptly on the occurrence of this emergency, and at a joint meeting, at which the boards of health of the town, county and State were all represented, proper measures for the restriction of small-pox were put into operation. The deliberations of these gentlemen in the presence of a problem which was quite new to nearly all of them, were marked by intelligent appreciation, breadth of view and promptness of decision, which fell into pleasant contrast with the narrow and unintelligent make-up and dilatory habits of certain other boards governing the sanitary affairs of other localities.

One of the two deaths from small-pox which occurred in Maryland during the year happened at Pocomoke City, in the case of a young, colored, pregnant woman, unvaccinated. The only other fatality was in an unvaccinated infant in Baltimore City.

The vaccination done in Pocomoke City and the vicinity during this time was very thorough, and left an inconsiderable residue of unvaccinated persons. Revaccination was also general.

The promptness and thoroughness of the local sanitary work kept down popular fear and the injury to local business interest was small and transitory. As is usually the case, the symptoms of panic were most apparent among the wholly unprepared communities of the adjoining County of Somerset. The County Commissioners of Somerset had never assumed any of the duties of a local board of health. Indeed, they had on many occasions distinctly repudiated all such obligations. The proximity of Pocomoke City to Princess Anne, the county town of Somerset, aroused the town commissioners of Princess Anne, who passed a general vaccination ordinance and called upon the County Commissioners for assistance. In the appeal to the County Commissioners, the State Board of Health joined, and it is believed that the County Commissioners knew what was asked of them. They appointed a vaccine officer and showed other symptoms of wakefulness.

THE OUTBREAK AT CUMBERLAND. The outbreak at Camberland was discovered by Dr. Miller, who reported it to Dr. Chas. H. Brace, Health Officer for Allegany County, who in turn telegraphed the information to the State Board of Health.

The first case was in the person of a white married woman, who could not trace her infection to any source. The inmates of the house were vaccinated and kept under observation, the sick person was carefully isolated and the house quarantined under guard. A subsequent case, traceable to this house, occurred in another part of Cumberland on a business street. This house was isolated by the construction of a fence and kept like the other one, under guard. The number of cases comprising this outbreak was small, numbering not more than four persons.

No account of the occurrence has been given to the State Board of Health, though a report was several times promised, and, if forthcoming, would probably have shown that the local health officer for the City of Cumberland managed the outbreak well.

THE SPARROW's Point OUTBREAK. This outbreak is spoken of in the report of Dr. Stevenson, Health Officer for Baltimore County. It was his first engagement, and he was able to conclude it in a very satisfactory manner.

This outbreak occurred under circumstances particularly favorable to restrictive methods. The community, of about three thousand souls, occupies land belonging to the Maryland Steel Company and derives its whole support from that wealthy corporation. The influence of the company, added to the authority of the sanitary officers, is sufficiently powerful to apply in a thoroughly effective manner whatever means are available for the restriction of infectious disease. The management of the company is in strong hands, and but for 'failure to notify the first case, and other errors detailed elsewhere in this report, the extinction of this outbreak with one or at most two cases would have been easily accomplished.

When control of the situation was undertaken by the Board of Health of Baltimore County on May 12th, the co-operation of the company was fully pledged, but the extent of the infection was unknown, and determinable only by house to house inspection. While the State Board of Health assisted in the work of suppression as far as seemed necessary, the chief burden of cost fell upon the local board of health and to them is due the credit of preventing an epidemic, which on the 12th of May was certainly impending.

The company is said to have spent much money, but their expenditure was the price of delay rather than the cost of small-pox.

OTHER OUTBREAKS. Two exceedingly suspicious cases occurred near Bowie, Prince George's County, in February, 1899, in the persons of two young ladies, one of whom had been employed as a saleswoman in Washington, though it could not be ascertained that she had been in contact with any case of the disease. These were very mild cases, indeed, but it cannot be said that the diagnosis of small-pox was beyond doubt. The weight of evidence seemed to favor that view. The cases were carefully isolated, and the family must be given great credit for patiently submitting to the recommendations of their family physician and the Secretary of the State Board of Health, especially in view of the doubt which was frankly confessed to them.

Near Cox's Station, in Charles County, a suspicious case was reported to the State Board of Health in September, 1899. It was promptly investigated and found to be a case of mild smallpox in a colored girl. Another case probably occurred in the same house, though the illness was very slight. The only circumstance which seemed likely to be connected as a cause with this slight outbreak was that a package of second-hand clothing had been received from Washington about four weeks before the occurrence of the sickness. There was in this bundle a dress, which was worn but once, and then by the girl who twelve days from that date had the prodromal symptoms of small-pox.

This family lived in an isolated house about half a mile from the village. There were but four persons in the house. A committee of citizens undertook the responsibility of maintaining the family during the necessary quarantine. A general vaccination was rapidly accomplished, and no spread of the disease occurred.

As To SMALL-Pox IN GENERAL. Small-pox has been quite prevalent in various parts of the country for nearly two years past, and has been epidemic at various times and places in Virginia, West Virginia and Pennsylvania. A somewhat serious epidemic prevailed in Alexandria last winter, and, as was expected, the City of Washington had a considerable number of cases.

Maryland had the good fortune to escape without a single alarming outbreak, and except at Sparrow's Point, had no very expensive or arduous work to do against it. If this good fortune is to be attributed to one influence more than another, it was probably due to the prompt recognition of the disease in its first appearance, and this in turn is ascribable to the carefulness of practicing physicians. Small-pox has of late years grown so unfamiliar that the very great majority of physicians in this State have never seen a case. Those who saw their first cases of the disease during the past year could not of course be expected to make the diagnosis with confidence, but they all had the courage and good sense to avoid the common blunder of mistaking the mild cases for chicken-pox. This error has been the chief contributor to epidemicity of small-pox in the United States. In some sections of Pennsylvania particularly the practicing physicians having committed this mistake, have clung to it with pertinacity, and in some instances with such blind obstinacy as to thwart all the efforts of the health authorities to control the disease. No single instance of this error has happened in Maryland, and the fact speaks much in praise of the intelligence and honesty of those physicians under whose observation the first cases fell.

The diagnosis of small-pox is by no means always easy even to those who have had large experience, and probably chickenpox resembles the disease more than any other eruptive disorder.

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TYPHOID FEVER. In the report for 1897 we offered as an estimate of the annual mortality of Maryland 880 deaths at the lowest, and 1240 as the highest number which the available data indicated. In the report for 1898 we said that extended observation showed the true typhoid mortality to lie, between these two extremes. Figures for the year ending June 30th, 1899, show that certainly no fewer (and probably a hundred more) than 904 persons died during that year of typhoid fever. The only correction which this estimate contains is that for the 45 per cent, shortage of the returns and for the typhoid content of the “Unknown” column. If the probable cases which are included in other mortality columns were added, the total number would be considerably increased.

To show the waste of life and health entailed by typhoid fever, let us imagine that all the cases of typhoid fever for a year should happen at one time and in one place, and should be cared for in somewhat the same manner, that is in dwellings. Nine hundred and four deaths suggest the sickness of not less than ten thousand persons. Ten thousand persons having typhoid fever would require for housing a city of the size of Hagerstown. Every five sick persons would give steady employment to two nurses and a laundress. Here, then, are 8,000 more inhabitants for an imaginary City of Typhoid. For every twenty patients we will allow one physician, adding 500 more inhabitants. The average duration of a case of typhoid fever is 42 days, so that for six weeks a population of 18,500 persons would have to be supported, without in that time producing one

penny worth of anything. If it cost to supply these people with the necessaries of life a little more than it costs to support the paupers at Bayview Asylum and a little less than it costs to support the charity patients in the hospitals, this City of Typhoid would cost in six weeks $222,000. If the doctors and nurses would considerately accept such wages as are ordinarily paid to cooks and laundresses, $153,000 would have to be added to the expense account.

So far we have not charged up anything for the cost of death. Funerals would occur in that city at the rate of something over 150 a week. At the price of a pauper funeral the 904 deaths would cost $5,624. If each citizen who died can be said to have been worth the price of a good cow, $40.00, the cost of the deaths will be increased by the sum of $36,169, bringing the total cost of running the City of Typhoid for six weeks up to $416,784. If these citizens are worth less than forty dollars each, it would be cheaper to butcher them all at the beginning of their illness. They could be butchered and buried for $62,500, or the remains could be sold to the tankage men at three or four dollars a ton, which would save the $60,000 funeral expenses and yield quite a profit.

If these latter suggestions in the direction of economy are not sufficiently revolting, there is but one more revolting manner of dealing with the problem of typhoid fever, and that is to permit this disease to go on year after year, collecting its ghastly tolls from the youth and vigor of the State, and holding its still more hideous menace over the thousands whom it does not quite destroy.

The appeal here made to figures is based upon the lowest cost which the number of cases of typhoid fever can be estimated to inflict. The average cost of an illness from typhoid fever on this estimate is but twenty-two dollars. The mere idleness of a citizen for forty-two days costs more than that. Necessary attention to each person sick with typhoid fever requires fourfifths of the time of a healthy person, and the thirty-three days of labor here involved are worth more than twenty-two dollars. Nevertheless the $220,000 which barely suffices for the support of those sick with typhoid fever, for an unproductive period of forty-two days, is a large enough sum certainly to arrest the consideration of the most thoughtless. If the average citizen were worth as much as a good slave, we should have to add four times as much for the cost of the 904 deaths. If the average citizen was worth what it costs a negligent corporation to kill one, the cost of death alone would be $470,000 a year.

One million dollars a year is under the total annual cost of typhoid fever in Maryland, and this waste of wealth is avoidable. It is possible to cut down the sickness from typhoid fever

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