that disease." The state therefore loses annually by a preventable disease in this valley alone $240,000 of its valuable and pro-* ductive rural citizens.

The people whom we met are not apathetic nor do they consider typhoid fever unavoidable, but they are in a receptive mood toward questions of sanitation and are anxious for instruction."

On account of the conditions mentioned in this report and the evident necessity of some systematic measures for their correction, the matter is brought to the attention of your board. I wish also to inform you that it is the desire of the Bureau to co-operate with your board to such an extent as may be practicable in public health matters, and on receipt of a request, I should be pleased to detail an officer to co-operate with you in work for the improvement of sanitation in the places mentioned in the above quoted report.

Respectfully,

RUPERT BLUE,

Surgeon General.

SECRETARY'S REPLY.

Wheeling, W. Va., Oct. 11, 1913.

Surgeon General Blue,

U. S. Public Health Service,
Washington, D. C.

Dear Sir:

Your letter of the 6th inst. received and I thank you for the information you convey. You may be assured of the hearty cooperation of the State Board of Health in all such matters as long as I have any connection with it. As a new member of the board, I am not quite certain as to the extent of our authority in effecting desired improvements in sanitary conditions. Heretofore, the appropriations for the board have been so trifling as to prevent the board from doing effective work in this direction. It amounts now to but $15,000, but we hope to do enough with this small amount to show the members of our legislature the necessity of increasing the amount appropriated.

You will pardon the suggestion that not all the typhoid fever which you report is due to the assigned causes (here the secretary gave an account of the outbreak at Dallas where the disease could not possibly be attributed to the causes named in the letter from the surgeon-general). I hear incidently of cases not unlike this. My predecessor as secretary of the board, Dr. H. A. Barbee, of Point Pleasant, wrote me recently that he had in his own practice 18 cases of typhoid fever, and that the disease is prevailing in the country districts about his town. Dr. Golden, of Elkins, the president of the board, writes me that the same is true in his neighborhood and the counties near him. These facts cause me to attach less importance to the causes which your reporter assigns for the prevalence of the disease in the South Branch Valley, but of course, I am in a measure an amateur in such investigations, and I of course, recognize the connection between the conditions reported in that region and the prevalence of typhoid, and therefore the necessity of effecting such changes as may be within our power in the hope of at least diminishing the morbidity and morality from this very prevalent

cause.

direction, and promising to do what is in my power to make
valuable to our people these investigations, I remain,
Sincerely yours,

S. L. JEPSON, M. D., Sec'y.

On October 17th, 1913, at the suggestion of Dr. Henshaw, County Health Ocer of Ferkeley County, I visite1 Martinsburg on account of the prevalence of typhoid fever in Berkeley county. On the 18th, in connection with Dr. Henshaw, Surgeon Lumsden of the U. S. Public Health Service, and Drs. Lefever and Hoffman, of Berkeley county, I visited many parts of the county by automobile, calling at many houses in which typhoid fever existed. In one family we found the mother and two children in bed with the disease. The usual unsanitary privy was found at all of the houses and at some of them the well in dangerous proximity. On the night of the 18th, a public health meeting was held in the Bunker Hill school house, which was filled to its capacity with the people of the neighborhood. An address on Typhoid Fever, Its Causes and Prevention, was delivered by Dr. Lumsden, after which I delivered an address on Smallpox and the Preventive Power of Vaccination, nearly one hundred cases of small-pox having recently existed in the county. Dr. Henshaw closed the meeting with some remarks touching the work that he is doing as county health officer, and in seeking the co-operation of the people in his unselfish efforts for their good. It was after 10 o'clock when the meeting closed and the people with apparent reluctance departed for their homes.

Unusual interest was manifested by the large audience, and it is hoped that much good seed was sown.

As typhoid fever continued to prevail for weeks after my visit to Berkeley county, and the county health officer was determined to do all in his power to control the disease, the following letter was, at his suggestion, sent to the surgeon-general of the U. S. Public Health

Service:

Surgeon General,

U. S. Public Health Service,
Washington, D. C.

Dear Sir:

Wheeling, W. Va., Nov. 1, 1913.

You will confer a great favor upon our board if you can detail an officer to visit Dr. W. T. Henshaw, county health officer at Martinsburg, with a view to an investigation of the typhoid situation in that neighborhood. The county is having a large number of cases of this disease and Dr. Henshaw desires to find its origin if this be possible. I had the pleasure of visiting a part of the county with Dr. Henshaw and Surgeon Lumsden some days ago, and we appreciate the help that has been given to us by your department.

With thanks in advance for anything that you may be able to do, I remain,

Very sincerely yours,

To the above, the following reply was received:

Dr. S. L. Jepson,

Washington, November 10, 1913.

Secretary State Board of Health,
Wheeling, W. Va.

Dear Doctor:

Your letter of the 1st inst. is at hand, and in accordance with the request contained therein Surgeon L. L. Lumsden has been directed to undertake investigation of typhoid fever in Berkeley County, W. Va., in co-operation with Dr. W. T. Henshaw, county health officer. It is the expectation that these investigations shall be continued, not only to determine the prevalence of typhoid fever and its methods of spread, but the measures necessary for its control. Preliminary surveys will accordingly be made this fall, and intensive studies subsequently taken up as the typhoid situation may require.

Respectfully,

RUPERT BLUE,
Surgeon General.

It may be interesting to state in this connection that 230 cases of typhoid fever occurred in Berkeley county during the recent outbreak, resulting in many deaths.

In June, 1914, Governor Hatfield inclosed to me a letter from a citizen of Piedmont, complaining of the prevalence of typhoid fever in that place. From the information contained in the letter I was led to believe that an epidemic prevailed in that community. On June 17th, I visited Piedmont and called into conference all the physicians practicing in the place. Each physician was carefully questioned as to the number of typhoid patients under treatment.

The result of the investigation showed that but three patients were in bed with the disease at that time, and there were three others convalescent who were able to sit up. It was ascertained, however, that this was about the close of an outbreak that had prevailed for some time, not only about Piedmont, but even more extensively across the Potomac in Maryland in and near the town of Westernport. A report recently received from the health officer of Piedmont, Dr. D. J. Long, gives the total number of cases occurring during this outbreak from June, 1913, to June, 1914, as 81, with two deaths, indicating that the type of the disease was very mild.

The prevailing opinion in Piedmont, among the physicians, as to the cause of this outbreak was as follows:

The water supply of the town comes from a small river, the Savage, two miles distant, the water of which is believed to be pure. At times, from some defect in the system of transportation, it becomes necessary to have water pumped into the reservoir from the Potomac River whose water can never be considered as potable.

Prior to this outbreak, one of these interruptions in the water supply had occurred, when the people of the community were compelled to drink Potomac River water.

I urged the necessity of having the water from the ordinary source

Board of Health, has since expressed to me the opinion that this water supply is not pure, and later this opinion was verified by analysis of the water. An analysis of water from four local sources was made at the State Hygienic Laboratory at Morgantown, and the result was as follows:

No. 1. From school house spring, unsafe. No. 2. From Savage river, unsafe. No. 3. From artesian well, safe. No. 4. From Wilson spring, unsafe. This examination was made in August, 1914.

In November, 1914, the health officer of Piedmont, reports that he does "not know of a single case in the city at the present time."

The above outbreaks are all of those which we have been requested to investigate. A letter, however, comes to us from Dr. C. C. Watson, of Albright, a small town of Preston county, which so well describes a condition that exists in many rural districts, that I qnote as follows:

"I think that the main cause of typhoid infection here is in the water. Our water supply is from wells and is gotten at a depth of about 15 feet, making it hard to keep out surface water. These are all dug wells, and some of the old ones are simply walled up with rock. There are 10 or 15 suspicious wells in the town."

In my sanitary investigations I have learned that the above is by no means a rare condition. Too many of the wells in villages and on farms are dug wells, many of them shallow, not carefully located with reference to the stable and vaults, and not properly walled or securely covered. It is a well-known fact that well water may become contaminated by drainage from a vault located quite a distance from the well. To prevent such contamination it is necessary to see that the well is properly located with reference to any surrounding source of contamination. It should then be carefully walled from the bottom up with cement joints, and covered either with cement or with tongued and grooved boards to prevent surface contamination. The life and health of the people in rural communities very frequently depend upon the adoption or neglect of the precautions here suggested.

It may be here remarked that, judging from the reports that reach this office, there has been very much less of this disease in the state during 1914 than in the previous year. Some of this is no doubt due to improved sanitation, but I can not but think that there are causes operating some years concerning the exact nature of which we are still somewhat in the dark. There is no doubt, however, that if the people would adopt generally the preventive measures now well understood by physicians, and which we have endeavored to lay before the people in the October issue of the Board of Health Bulletin, the amount of typhoid fever in the state could be very greatly reduced.

TRACHOMA.

The United States Public Health Service, in the pursuance of an investigation as to the prevalence of trachoma in the mountain regions

a suggestion from that service, sent into this state in September, 1913, Surgeon Taliaferro Clark for this purpose. Dr. Clark began his investigation at Wheeling where the school children were examined, and out of 2,224 children but one case of trachoma was found. The following table, extracted from the official report of Surgeon Clark, indicates the great prevalence of this disease in our state.

The above table clearly indicates that in Wyoming, Wayne, Mingo, McDowell, Logan and Boone counties an excessive amount of this very serious disease exists. It may be well here to explain that trachoma is a chronic inflammation of the eye-lids of an infectious nature. For years the disease has prevailed extensively in the neighboring counties of Kentucky and Virginia. As Dr. Clark remarks in his report, "a sharp line of demarkation, represented by the Clinch mountains, separates the infected territory from the other counties of this section of the state. The infection, as in similar territory in West Virginia, is wide-spread in the counties where the disease was found to prevail. From a public health point this is one of the most important and significant facts brought to light by this survey. The wide dissemination throughout a large part of the population of this state of a disease so potentially damaging to vision as is trachoma, and the threatened economic loss to infected communities, should be a matter of serious concern to those in charge of the public health administration of these communities."

Dr. Clark states that by far the largest number of cases examined by him were among school children, but that he also found a number of cases among adults in his house-to-house inspections. The fact