"Quite a number of cases occurred in the city after the close of our fiscal year. These are not included in this report.

In view of the conditions found, the following recommendations were submitted, and are applicable to every city in the state:

Recommendations.

The quarterly or semi-annual inspection of grocery stores at irregular intervals, without announcement.

The placing of the stores upon a score card basis, the proprietor being furnished with a copy of the score card and a written list of improvements ordered.

The licensing of all grocery stores with only a nominal fee, a prerequisite for license being the presentation of physician's certificates showing all employees to be free of tuberculosis and syphilis.

A city ordinance requiring the enclosing, within paper bags at the bakery, of all pies offered for sale. Bags of waxed paper are recommended. A city ordinance prohibiting the sale or offering for sale of any foods which are to be eaten uncooked and which have been stored outside of any store in the city, or stored within twelve inches of the flooring of any store.

A city ordinance prohibiting the sale by groceries of any liquid or sub

stance containing over 2 per cent of alcohol, or containing morphine, heroin or cocaine.

The legal prohibition of the sale of sausage, bologna or other meat which has been dipped into or wet by any solution to preserve or color it.

Food Specimens Submitted to the Hygienic Laboratory for Analysis. Zanzarine, “a mixture of uncertified analine color and sodium chloride," as stated on the label of the Preservative Manufacturing company; a dye used for imparting to sausage a deceptive red coloration to overcome the slight browning effect which boiling causes in meats.

Specimen collected April 14th, 1917, at Charleston. Analysis made by Mr. A. A. Cook, state chemist, showed the chief constituent of the dye to be chryscidine yellow mixed with an appreciable quantity of naphthol yellow and a small quantity of another coal-tar dye not identified. Both dyes are non-permitted coloring matters under the Federal pure food law. A qualitative test of bologna which has been colored by zanzarine showed the dye to be concentrated in the skin and in the meat directly in contact with it. The meat of sausage dipped in the dye is, therefore, contaminated by a coal-tar stain which is not sanctioned by the government. "Sage mixture" for use in preparation of sausage: Microscopical examination showed it to be composed of powered sage leaves and white pepper.

DAIRY FARM ISPECTIONS.

Investigations were made of 57 dairy farms in ten counties, the farms being scored on a specially devised, simple but practical score card and the dairymen given advice when needed.

The dairy farms of Marshall and Wood counties were inspected and scored by Dr. C. R. Weirich, and relatively were given slightly higher scores than were the other farms, those scored by me. The variations in my scores can be explained by local influences. The dairies around Morgantown sccre much higher than the others as a result of the work of John L. Core, V. M. D., dairy inspector for Monogalia county, who has accomplished a thorough cleaning of the dairy barns and a screening of all milk houses, the building of several milk houses and other improvements.

INVESTIGATION OF THE CHARLESTON TYPHOID FEVER

OUTBREAK.

By Harold B. Wood, M. D., Assistant State Health Commissioner. An epidemic of typhoid fever, exceptionally mild in virulence, involved Charleston between April 20th and June 18th, 1917. There were 163 known cases of typhoid fever with one death.* The infection was water-borne. Charleston, W. Va., a city with an estimated population of 31,960, situated at the junction of the Elk river with the Kanawha, derives its water supply from the Elk river. The intake is at the waterworks upon the eastern side of the Elk river at the upper border of the city. The percentage of homes connected with the municipal water supply is high, as is that of the houses having sewer connections. A survey made by the sanitary engineering division of the West Virginia State department of health in 1917 showed the presence of only 189 wells and 1332 yard privies, the unsewered houses being principally in the outlying districts and in a few congested negro sections. These wells and privies were located and mapped by Mr. Mayo Tolman, chief engineer.

The municipal water supply is furnished by a private corporation, the West Virginia Water and Electric company. The waterworks is equipped with a mechanical filtration plant and a chlorine gas chlorinator was installed in March, 1917. The management was instructed to use aluminum sulphate and lime as coagulants. The clorinator is of dry feed delivery and of satisfactory design. The water supply is the Elk river, the intake being located at the pump house within the city limits and about 1100 feet above the nearest sewer outfall.

The Elk river is notably polluted. Its watershed is approximately 1900 square miles. The population, although small for the acreage, is distributed almost wholly along the Elk river and its branches, and discharges all wastes into the river or upon its banks. Typhoid fever is always present in the Elk watershed. Seven physicians report having treated during the first five months of the year patients with typhoid fever who were living along the Elk river, and all of whom had been drinking raw river water from the Elk. The outbreak of typhoid at Clendenin, twenty miles up the Elk river, occurred in January and February, with return cases in May. Twenty-seven cases were reported from Gassaway, ninety-one miles upstream, during the first five months of the year. A total of fortyseven cases of typhoid were reported as occurring in the Elk watershed this year previous to the Charleston outbreak, the patients being consumers of raw Elk water and emptying their discharges into the same river. There is, therefore, even during the spring months, constant con

tamination of the Elk river.

The typhoid outbreak appeared as three waves, the first being May 1, 1917. There was a known total of 163 cases, of which 153 were reported up to June 26th. Although no special attempt was made to ferret out unreported cases, 20 unreported cases were found while searching for the reported cases. The residence of nearly every known case was visited

Quite a number of cases occurred in the city after the close of our fiscal year.

this report.

These are not included in

for epidemiological data, Mr. A. N. Wardle, assistant engineer, visiting 26 homes and Dr. H. B. Wood, assistant commissioner, visiting 129 homes. The various distributions were as follows:

There were 135 families involved in the outbreak. Since there are 8158 domestic gas meters in use in the city, and presumably about that many families, about 1.6 per cent of the families were involved.

The milk supply of the city comes from 1213 cows on 148 dairy farms producing 1724 gallons of milk daily. The 135 typhoid families received their milk from just 50 different sources, exclusive of the 17 families using wholly condensed milk, the 8 having their own cow, the 12 patients who used no milk whatever and the 11 who were unable to give the source of their supply. Of the 96 typhoid persons who obtained their milk from dairies, not over six obtained their supply from any one dairy. This eliminates the milk from the list of possible causes of the outbreak.

The ice in Charleston is entirely manufactured and comes from two plants situated within the city. The ice is frozen from distilled Elk river water and is safe. The ice companies have daily city outputs of 21 and 55 tons, respectively, the family consumption being during May about 15 and 40 tons. Of the patients giving the data about ice supply, 26 patronized the smaller ice company and 50 the larger. Search failed to reveal any typhoid carriers among the delivery men who recently had had typhoid fever. The ice did not cause the typhoid outbreak, since the ratio of customers of the two companies about equals the ratio of their general output. Other food supplies can be ruled cut as the possible source, as there was no source or store which was in common or prominent usage.

Fly season had not commenced when the outbreak prevailed, June 18th being the apparent beginning of fly season this year. Only four of the typhoid cases lived in unsewered houses.

Personal contact was a possible source in only six cases.

Importation occurred once, in a boy who was sent while ill from Posey to the Davis Child's Shelter.

The water is the only remaining possible source of the typhoid epidemic. The outbreak was due to the high water and backward flow of the Elk river forcing the city's sewage into the intake and the delivery to the people of insufficiently-treated water.

Government gaugings are made of the Kanawha river at the south side bridge at Charleston and also of the Elk river at Clay, 50 miles up stream from Charleston, and of the Kanawha river at Kanawha Falls, 36 miles up stream. When high water from a storm appears at either of these upriver points the crest appears at Charleston at about 8 and 12 hours later, respectively. Four miles below the city is Lock No. 6 in the Kanawha river, where is located a dam with a Canoiane wicket gate. When the dam is raised it backs the water several miles up the Elk river, according to the government engineers, and causes an upward drift of floating objects and sewage, according to the testimony of numerous observers. This gate having been down for a few months, was raised April 20th. Twelve days later the cutbreak of typhoid fever commenced. This would not have occurred if some provision had been made whereby the water company could anticipate and expect an upward flow of the city sewage to their intake.

Late in April heavy rains prevailed over the Elk and Kanawha watersheds, and again in the second week of May. These rains each caused a two-foot rise in the river and an added burden upon the filters and increased contamination by sewage. The result was the appearance of two renewed outbreaks in the typhoid fever. During the three rains the precipitation at Charleston was 2.38 inches on May 27th, 1.10 inches May 28th and 70 inches May 29th. Heavy rains prevailed over the watersheds on May 26th and 27th, with resulting enormous increases in the gauge readings, from 2.2 feet increased to 15.7 at Clay on the Elk, and from 2.6 to a gauge reading of 10 feet at Kanawha Falls. As an offset the gate at Lock No. 6 was lowered May 27th while under a head of 3.6 feet. This had the tendency to increase the current at the waterworks and to more completely drain the city sewage away, although the river up stream kept rising. This lowering of the dam was a factor in reducing the typhoid fever. Upon June 9th the gate was closed, increasing the gauge readings from 4.6 to 7.1. with a corresponding upward flow in the sewage in the Elk river.

The investigation proved that Charleston is supplied with the Elk river water with an added pollution, during high water, by the city's own sewage. Although equipped with a mechanical filter and a chlorinator, the public water as suppplied has been a menace and has been the direct distributing agency of the typhoid infection. This statement is borne out by the facts elicited.

The investigation by the State department of health was begun May 14. Up to this time only 7 cases of typhoid had been reported; two on May 1, one on May 8, one on the 9th, two on the 11th, and one on the 14th. Suspecting a beginning infection of possible sericus consequences. Dr. H. B. Wood began an investigation on May 14. The homes of five cases were visited and the water was found and reported to be the only probable cause of transmission. Soon after this the Commissioner of Health gave this opinion publicity, with the advice to the people to boil the drinking water and to get immunized as a further safeguard. From May 15 to 31st Dr. Wood was away on a tour of investigation through the