seeking out and helping care for the sick, especially for cases suspected to be infectious. These nurses rendered excellent service not only in finding and helping care for the sick, but also in the course of their frequent rounds-practically house-to-house canvasses-of the town in obtaining for the relief committee specific information about the need of foods and clothing among the flood sufferers.

All of the practicing physicians of the town were communicated with directly and their cooperation was requested in respect to the prompt reporting and the carrying out of prophylactic measures about recognized and suspected cases of infectious disease. At a citizens' meeting on April 6 the people were advised about sanitary measures to carry out in their homes. The local newspaper, as soon as its printing machinery had been repaired from damage by the flood, rendered excellent service by giving conspicuous publicity to sanitary matters. A general spirit of cooperation appeared to prevail in the community and the work of sanitation progressed well.

By April 11 Catlettsburg was probably in better condition from a strictly sanitary standpoint than it was before the flood. No evidence of any outbreak of any infectious disease had appeared and the work of sanitation was being continued at a good rate. On April 11, before leaving Catlettsburg for a trip in the western end of the State, the writer, at a meeting with the mayor and city council, submitted the following recommendations:

1. Require a prompt report to the health officer of all suspected and recognized cases of typhold fever and of other infectious diseases. 2. Have rigid precautions exercised, under official supervision, about the bedsides of all cases which could reasonably be suspected to be infectious in nature, and, so far as might be practicable, have all persons sick with typhoid fever or other dangerous communicable disease sent for care and treatment to the hospital in Ashland.

3. Appoint a well-qualified man as assistant health officer, with a salary adequate to justify requiring him to devote all of his working time to health work.

4. Have continued, under necessary official supervision, the clarification and the hypochlorite treatment of the public water supply.

5. Have all shallow dug wells on premises where other and safer sources of water supply might be available permanently closed.

6. Assist with public labor so far as might be necessary the rehabilitation and sanitation of privies, and require all occupied houses to be provided with either properly connected water-closets or reasonably sanitary privies.

7. Have the cleaning of streets, alleys, yards, and houses continued at as rapidly an increasing rate as might be practicable.

8. Have the public water supply protected against pollution from the foul water discharged through Hampton Branch, either by having

the intake of the water system carried up the river to some point above the mouth of Hampton Branch or by having the section drained by this creek sewered and the sewage discharged at points downstream from the present location of the intake for the water supply.

9. Enact and rigidly enforce an ordinance requiring all habitations within the publicly sewered and watered area to be properly connected with the sewerage system.

10. Have the sewerage system extended as rapidly as practicable to cover the whole town.

11. Require all privies in the town to be made fly proof, to be provided either with water-tight receptacles above the surface of the ground or with properly walled excavations below the surface of the ground to receive the excreta, and, under official supervision, to be maintained at all times in good sanitary condition.

12. Have condemned as unfit for human habitation all properties which could not be made reasonably sanitary.

Of these recommendations the first seven were urged as feasible for immediate adoption, and the last five were urged as permanent policies to be adopted and carried out as rapidly as circumstances might permit.

The writer returned to Catlettsburg on the afternoon of April 17. He found that the general work of sanitation during his absence had been progressing at a gratifying rate, but to his surprise and disappointment he learned that the public water supply was again highly turbid and had been so since the day before. On inspection by the writer and the local health officer it was found that the reservoirs had been allowed for some reason to become nearly empty and the water was being run through them without time being given it for proper sedimentation to take place. The operation of the hypochlorite plant had been discontinued, and the public water supply, so far as its mud content and its potential dangers from pollution at the intake were concerned, was in just about the same condition as it was when inspected on April 4. Furthermore, at the time of the inspection on the afternoon of April 17 deposits of human excrement (at least eight in number) were found on or near the banks of two of the storage reservoirs on the hill. Several of these deposits were on the side of the bank sloping toward the reservoirs and at one point less than 6 feet from the water's edge. These necessarily would have been washed into the water supply had heavy showers of rain occurred. It was obviously possible for any of the deposits near the bank or on the slope of the bank distal to the reservoirs to be carried by insects or worms or on the feet of persons or animals to the slope of the bank over the water's edge or actually into the water. The presence of these deposits in the immediate vicinity of the hypochlorite plant denoted a gross care

lessness on the part of the men who had been operating the plant or on the part of those who were supposed to exercise vigilance to protect the water supply against readily avoidable nuisance.

At the time, however, the presence of these deposits did not suggest anything like as great potentialities of danger as did the contamination of the water supply with the discharge from Hampton Creek, since its mud content indicated that the water as then distributed was not being effectively treated by purification methods after it entered the water system at the intake. Before a meeting of the city council on the night of April 17, the writer reported on the condition of the water supply, stating that, in his opinion, the public water supply as then being distributed was unsafe and recommended (1) the exercise of official supervision over the operations of the public water system and (2) the enactment of an ordinance requiring that the public water supply as distributed to the town should not at any time contain more than one (1) colon bacillus to the 50 cubic centimeters of water-fermentation with gas production in standard lactose bile or lactose bouillon to be accepted as evidence of the presence of the colon bacillus and the examinations of the water samples to be conducted according to the following method:

Incu

Plant 10 c. c. of the water in each of 5 fermentation tubes. bate the planted tubes at about 37° C. for 48 hours. Accept the production of gas in none or only 1 of the 5 fermentation tubes to mean not more than 1 colon bacillus to the 50 c. c. of water. Accept the production of gas in 2 or more of the 5 fermentation tubes to mean more than 1 colon bacillus to the 50 c. c. of water.

Since that meeting the city council of Catlettsburg has appointed an assistant health officer; has named a full city health board, consisting of five representative citizens, with the health officer as secretary of the board; has passed a drastic ordinance requiring the public water supply at all times to be within a certain bacterial standard of purity; has ordered the local waterworks company to remove the intake of their receiving pipes up the Big Sandy River to a point above the mouth of Hampton Branch, and to build a close-meshed fence at least 5 feet high around the reservoir; has passed an ordinance forbidding trespass on the property of the waterworks company in the vicinity of the reservoirs; and has appointed a committee to investigate and report on the cost and feasibility of extending the local sewerage system, of installing a garbage incinerator, and of providing for improved methods of collecting and disposing of night soil, garbage, and other city refuse.

Since April 17 there have been no outbreaks or unusual prevalence of any infectious disease reported in the town, the general work of

1 From Apr. 20 to June 7 there have been reported in Catlettsburg and its immediate vicinity only five cases of typhoid fever, and all of these cases developed among persons residing in the Hampton Branch section.

cleaning up has gone on at a good rate, and from present indications Catlettsburg will socn occupy an advanced position in hygienic

progress.

MAYSVILLE.

Maysville, with a population of about 10,000, including that of suburban villages, was flooded at the same time as was Catlettsburg. About 65 per cent of the houses in the city were in water. The conditions occasioned in Maysville by the flood were, though proportionately of less extent, strikingly similar in character to those observed in Catlettsburg.

The public water supply for Maysville is obtained from the Ohio River. The intake is downstream and only a few hundred yards from the outlet of one of the main city sewers. The water supply is treated by the use of a coagulant (lime and iron) and mechanically filtered. The waterworks were incapacitated for three or four days during the period of high water, and on those days water from various sources, including springs, wells, and cisterns in the hills, was conveyed by means of boats to homes in the flooded sections. About 60 per cent of the houses in the city are connected with the watercarriage sewerage system, and the others are provided with privies or cesspools, almost all of which are of insanitary type. The area of the city which was flooded was in large part comprised by the nonsewered sections.

Typhoid fever is quite prevalent in Maysville, about 100 cases occurring in the city each year, and several cases were under treatment when the flood occurred. No cases of smallpox had been known to exist in the city for some time prior to the flood, and none was found in the period of the flood. There had been since the beginning of the year about 30 cases of cerebrospinal fever, and several cases were still under treatment at the time of the flood.

Several hundred flood sufferers were domiciled temporarily in large warehouses which were connected with the sewers and were readily kept in reasonably good sanitary condition. The writer arrived at Maysville on the night of April 8 and on the following morning conferred with the members of the city board of health and the county health officer and made with them a sanitary survey of the city and its environs. The work of sanitation under the direction of the city board of health evidently had been carried on energetically. Most of the débris and mud left by the flood had been cleaned away. Quicklime had been sprinkled liberally in yards and alleys. Basements and cellars were being pumped out and disinfected. A liberal supply of antityphoid vaccine had been obtained and the administration of it offered free of charge. The merits of this agent were given for several days conspicuous and

extensive publicity through the local press and in other ways, and the afternoon of April 9 was designated as the time on which the extensive plan for the inoculation of the people was to be put into operation. On that afternoon a number of stations for administering the prophylactic were opened at school buildings and other public places in different parts of the city, so as to be convenient to the whole population. To assist the health department officials in the operation of these stations the services of a number of the practicing physicians in the city had been obtained. At the appointed time on the afternoon of April 9 the physicians with their assistants and equipments were at the different stations ready to do business, but no one appeared at any of the stations to receive the inoculation. Thereupon the maintenance of the public stations for antityphoid inoculations was discontinued, and in the several days following not more than 5 or 6 persons applied for and received the inoculations. After completing his sanitary survey of the city on April 9 the writer, at the request of the city health department, made before a meeting of the city council and board of health of Maysville a formal report embodying the following recommendations:

1. Treatment of the city water supply with hypochlorite of lime (containing 30 per cent of available chlorine) 10 pounds of this chemical to be used in each million gallons of water.

2. The distribution of hypochlorite solution for use in the treatment of drinking water in homes.

3. Treatment of every privy and cesspool in the city with a solution of quicklime-10 pounds of the lime in 10 gallons of water to be used in each privy or cesspool.

4. Obtainment of four Red Cross nurses to help find and care for the sick, especially cases of infectious disease.

5. The enactment and rigid enforcement of an ordinance requiring every house in the sewered area to be properly connected with the sewerage system within the earliest time reasonable-60 days being suggested.

6. The extension of the sewerage system as rapidly as practicable to cover the whole city.

The council at once by resolution adopted these recommendations, and the mayor appointed a committee, composed of one councilman from each of the six wards of the city, to cooperate with the city board of health to see that the recommendations were carried out. Said committee was empowered to employ all necessary equipment for carrying out the recommendations. The writer returned to Catlettsburg on April 10.