CONCLUSIONS AND RECOMMENDATIONS.

As was said in the beginning, the delay in engaging experts to investigate the cause of the epidemic at Elizabeth College for seven weeks after the epidemic broke out is fatal to an absolute determination of the specific cause of that epidemic, but the conditions found at McD. Watkins' dairies, which supplied milk to the College from April 19 until the end of the term, on the watershed and at the filter plant of the public water supply and at the ice plant of the local ice company were such that it needed only the bacteriological analysis of the samples of water taken at these various places to confirm my conviction that all of these sources were badly contaminated, and any of them might have been the cause of the epidemic. There were several cases in the city where the people were using city water. But from the fact that the sanitary conditions in and about McD. Watkins' dairies were found to be so bad, the can and bottle washing so inefficiently done and his spring and well waters so badly infected, the evidence is certainly strong that the fever did come from using his milk. The chemical analysis of his spring water also showed that the chlorine, nitrates and nitrites were high.

There is no evidence to show that the typhoid did or could originate on the College premises. When the changes recommended in the plumbing are made, the conditions in and about Elizabeth College will be perfectly healthful. It is located in a beautiful spot on the outskirts of the city on a plot of twenty acres, and is surrounded by beautiful great oak and other trees, and would seem to be an ideal place for seclusion and quiet study. I have no suggestions or recommendations to make regarding the management of the institution, except that it would be wise to enlarge the College dairy, so as to furnish all the milk needed on the premises. The conditions about the barns can then be kept thoroughly sanitary and a watchful eye can be kept upon the dairymen to see that they are cleanly in all of their operations in handling the milk. This dairy should furnish milk enough to supply all that is needed for ice cream and it should be made on the premises.

Until after an expert bacteriologist has been employed by the city for a sufficient time to allow him to become thoroughly acquainted with the filters and to operate them in a scientific manner, and until be can assure the people that he is getting at least 98 per cent. bacterial efficiency from them and no B. coli in the filtered water, all drinking water used at the College should be boiled at least ten minutes, placed in closed jars and cooled for drinking purposes.

The habit of putting ice directly into milk and drinking water should be stopped, and if the ice company could be persuaded to abandon the old gold-mine shaft as a source of water supply and to freeze its ice in such a way that the process would stop before the center of the block is frozen, and the blocks be split so that the mid

dle portion could be thrown away, much purer ice would be furnished to its patrons. I understand that this method of freezing ice is in successful operation in several cities.

Since returning to my home, Dr. Anderson and myself endeavored, at the request of his Honor the Mayor and the Water-Supply Committee, to find a suitable man to take charge of the city filter plant, and I am in hopes that by the time this report reaches your hands he will be on the spot and in charge of its operations. As soon as he bas matters well in hand at the filter plant he should turn his attention to the wells and springs, and if any of them are found to be infected they should be filled up at once.

I noticed at the dairies which I visited that the milk was being chilled by spring or well water which had an initial temperature of about 58 degrees; no ice was being employed. This would indicate that the milk was not chilled to a temperature lower than about 60 degrees before being bottled. It was then put into cans or bottles and delivered to customers without ice being used to keep it cool. This means that bacteria could and probably did multiply enormously in the milk between the time it came from the cow and its delivery to the customers. The most approved method to-day, and that required in large cities, is that the milk shall be chilled immediately after milking to 45 degrees and shall be kept at that temperature until delivery to the customers. All empty milk cans and bottles should be thoroughly sterilized before being used again. In order that these things may be done and that pure milk may in the future be guaranteed to the citizens, all the dairies furnishing milk to the city should be brought under the supervision of the City Bacteriologist. Respectfully submitted,

WILLIAM W. LOCKE,
Sanitary Engineer.

SOUTH FRAMINGHAM, MASS., July 26, 1906.

REPORT OF MR. D. A. TOMPKINS, CONSULTING ENGINEER.

CHARLOTTE, N. C., August 13, 1906.

TO THE HONORABLE BOARD OF WATER COMMISSIONERS,

TYPHOID AT ELIZABETH.

Charlotte, N. C.

The fever was caused by infection of some of the food in the College from some outside source. It may have been any of the food served at the College table.

Although the city water was bad, the epidemic was too acute to have resulted directly from the water. This is proven by the can

vass of many cases of fever in the city and by the fact that day scholars who used the water, both at the College and at home, had no fever.

Mr. McD. Watkins' milk was not the cause of the epidemic at the College. If it had been, the examination of the city cases would surely have revealed typhoid along his milk route, which it did not. Also many who drank milk did not have the fever and a number who had the fever did not drink milk at all.

It was not the plumbing. Reasons why not the plumbing are given by Mr. Locke very fully in his report.

The infection in the food came from outside the College. There was no fever in the College up to the time of the outbreak and no cause inside the College seems to exist.

The only original sources of typhoid fever found are:

1. The city water.

2. Well water in or near the city.

(From one of these two sources all the infection probably originally came).

3. Milk may be a possible source of infection.

The infection of the city water comes from these causes, to-wit: (1) That the water-works plant is new and the pond was not properly cleaned out before it was filled; (2) the watershed has never been properly subjected to inspection and control; (3) the new plant has not been properly operated; (4) well water has been permitted to be used without any knowledge as to whether it is safe or not.

REMEDIES.

1. Put the city watershed under proper inspection and control.

2. Employ a bacteriologist to give his whole time to the city water supply, including all wells. When wells are found to be bad, condemn and fill them up.

3. Let the College dairy furnish all milk used by the College for drinking purposes and for ice cream.

I regard it useless for Elizabeth College to build a private waterworks when the city water can be and should be made to meet every requirement. The city is in position to furnish a pure water supply because it has a plant adequate to do the work and it is in a position to buy the necessary knowledge and skill to operate this plant properly and get the results desired. Its guarantee should stand far ahead of assurances of those operating private water-supply plants. In matters of economy and health the city is in best position to furnish a supply of abundant and pure water to its citizens.

In the absence of a pure supply of water from the city, Dr. Lewis' recommendations as to a private supply is the only alternative. When the water-works are properly operated and the infected wells are closed up and the milk supply is produced on the place, the

original causes of typhoid will be removed, and such sporadic and acute infections as that at the College will be impossible.

4. Repair plumbing as recommended by Mr. Locke, not because the plumbing could have had to do with the fever, but simply to improve it.

I regard it to be exceedingly important that city records be kept in the future, giving full facts relating to food and water supplies of each case of fever. These records should be kept by the bacteriologist in charge of the water supply. He should have full control of water-works, watershed, and all matters relating to water supply and diseases resulting from bad water, with power to act.

If the city will assure the College of the accomplishment of the above remedies, then the College can in good faith and with confidence and clear conscience assure its patrons.

D. A. TOMPKINS,
Consulting Engineer.

REPORT OF THE SECRETARY OF THE STATE BOARD OF

MR. CHARLES B. KING,

HEALTH.

President Elizabeth College, Charlotte, N. C.

DEAR SIR-In compliance with the request of Dr. Misenheimer, Physician to the College, and of Hon. D. A. Tompkins, who had been called in by him to lend his aid as a sanitary engineer in the investigation of the outbreak of typhoid fever in your institution in May last, I visited Charlotte on June 30th. I immediately entered into conference with the gentlemen named and Mr. W. W. Locke, a sanitary engineer of high standing, at present employed as general sanitary inspector of the Metropolitan Water and Sewerage Board of Massachusetts, who had been employed by the College as an expert

and who had arrived a short time before. After a discussion as to the best method to pursue in making the investigation, we four made first an inspection of the College, then of the two dairies of Mr. Watkins, from whom the College had bought milk, and interviewed the purveyor of the ice cream used in the institution. After this we further discussed the problem and it was agreed that as the exigencies of my office would not permit my remaining longer on the ground the reports of Mr. Locke and of Passed Asst. Surg. J. F. Anderson, Assistant Director of the Hygienic Laboratory of the United States Public Health and Marine Hospital Service, whom General Wyman wired me he would send in response to my official request as Secretary of the State Board of Health would be submitted to me, and that I would then give my opinion as the representative of our State Board of Health.

A copy of the report of Dr. Anderson was received on the 20th inst. and one of Mr. Locke's this morning. At Mr. Locke's request I sent him the findings in the water analyses which, it was agreed, should be made in the United States Hygienic Laboratory at Washington, but was careful not to give any information as to Dr. Anderson's conclusions, so that the two reports were made independently. Both reports were very full and complete, and showed that the investigation was carefully, thoroughly and scientifically made.

After reading both reports and duly considering the data given, I agree with them in their conclusions, which you have observed are essentially identical. Expressing it more in detail, my opinion, based upon their findings and my own personal observation, is:

1. That there was nothing about the College itself that could have caused the outbreak. I am positive in my conviction that the sewerage of the building had nothing whatever to do with it. In my investigation of the epidemic of typhoid fever at the State Normal College at Greensboro, in 1899, I found that the sewer immediately beneath a battery of water-closets in the main building was broken, that the soil around it was saturated with sewage and that, too, within three feet of the opening for ventilation in the wall of a closet in which the butter supply was kept, so placed that the entering air was compelled to pass directly over it. The general-practically unanimous-opinion was that the broken sewer was the cause. I did not, however, agree in that opinion, and the final result of the investigation showed the correctness of my position. I enclose a copy of that report.

2. That the most probable cause was the milk of the Watkins dairy, chiefly for the reason that it was a new element that entered into the life of the school at a time that would come within the incubation period of typhoid fever and that the sanitary conditions of the dairy were such that the milk might be infected. But it must be borne in mind that of those who were sick probably at least six did not drink raw milk, while some who were not sick were inveterate milk drinkers, and the servants, who also drank the milk, were unaffected; and, so far as we are informed, typhoid was but little, if any, more prevalent among the numerous patrons of that large dairy than among the rest of the population. So we cannot be certain that the Watkins milk was to blame. I find myself unable to disabuse my mind of a serious suspicion of the ice cream. Practically everybody ate the ice cream except the servants. It was not eaten every day; usually only once a week. The outbreak of thirtyone cases, six the first day and all within a week, over 33 per cent. of the whole school resident in the College, or 18 per cent., admitting only seventeen to have been genuine, was in the nature of an explosion-the sudden action of a single agent not continuously at work. It is not impossible that a single can from the Dotger dairy,