MAY, 191,  CALIPORNIA STATE JOURNAL OF MEDICINE

permitted to go without `other support than that
atIorded by. the perly applied graft in the spine.
They should be placed face downward on pillows
or a .pwly. prepared' bed until the wtind overei
thl. mine is ,sufficiently sound to bave all sutures

~TemOkd.         . .
'  After the Hibbs opkation `ztupport to the spine
is nee&sarv. & `it .till be so disturbed as to in-
&em s&&sly with the result.
  Great `care must be exei-cised in handling these
patients,`and in removing them from the opehting
mom to' the bed;. not to thoroughly wreck all the
work done at operation.

Patienti that ,are' Gery we& and aemic should
under .&.~&rcumstan~& be operated upOn until an
efforts hti been made to' build them up so as to
endure both. the anesthetic n'nd the operation.' The
application. pf the. prikipb of Crile's anoci asso-
ciation should be always observed.

The patient <with abscessq from which pus can
contaminatk `the.- wound and gain acc& to the
transplanted bone in the spine, should seldom be
operated upon until the sinuses have healed and
the pus can be cxcladed.

Cases where a tubercular deposit is connected
with thi? spinous probes , where pus my not have
formed, but where tubercular tissue might break
down and cause pus, form a probkm which must
occasionally be dealt with, . If the .tubercular de-
posit is dissected .out first and the wound permitted
to heal before attempting an A&e operation, it
may heal >only temporarily and we may have a
larger tubercular abscess to.dcal with'than if it had
.not beeri touched, If we, dissect out a mass of
.tubercular tissue and place in a transplant, we
.may get a' union of the bohe to the spine, and
.then .have half of the transplant destroyed later
.on by tikctilar disease. A tubert%lar sac over a
spinous process, especially: in cases which have been
long on a stretcher -frame or hatie, been roughly
handled by `ostkopathic therapy, is not an unknown
.experience; it affords x grave problem in consid-
ering an Albee or a Hibbs operation.
Where there is any liability of the &d of the

bone' transpIant becoming loose before union takes
place between the transplant a6d the spinous
`process, a silver wire `suture is an excellent thing.
.The ,suggestion of silver wire is not original with
the writer.
The earlier tuberculosis of the spine is dis-
-covered and operated upon by one or other of the
methods above mentioned, the more ideal will be
the results. All physicians, no matter what their
line of practice may be, should use their best
,cndeavors to have parents, or those having chil-
,dren, in charge, take the children occasionally to
the family physician. The child should be stripped
.and its body carefully scrutinized for any possible
,disease or deformity. This + quite as necessary as
taking a child ,to the dentist to have the teeth in-
sfiected and make sure there is no source of dis-
case lurking in the mouth. Parents should not be
-taught to attempt to diagnose conditions for them-
selvr `, but they should be taught to take their
-chil en regularly and frquently to have a thor-
augh examination.  The proneness of many prac-

titioneQ to ask a few questions and write a pre-
scription, without stripping i patient even when
the patient comes complaining of symptoms that
ought to arouse suspicion of disease of the bones
or joints, accounts for many of the diognoses
ticketed "rheumatism."  Rheumatism is getting to
be almost as disgraceful a cloak for ignorance as
its predecessor %crofula."

Cases of turberculosis of the cervical spine
should not +e operated upon by either the Hibbs
or the Albee method.  Infants can be better
treated by the wire cuirass or a properly applied
plaster of paris cradle. Older children thrive very
much better and get well' very quickly and very
successfully by the proper application of a plaster
of paris jacket and jury mast zs used by the late
Lewis A. Sayre, These children can play about in
the open air so happily &nd so comfortably with a
proper jacket and jury mast and get well so
quickly as compared to cases where the disease is
lower down in the spine, that there is no neces-
sity td disturb them by an operation which, be-
cause of the anatomical peculiarities of the vertebra
and the possibility of injuring the very soft struc-
tures, is likely to fail or worse.

.

Of course, an operation might be advisable in a
case in the lower cervical region which laps over
into the dorsal region.  Rut in purely cervical
cases, or in high cervical cases, an operation should
not be attempted.

I wish to emph'aize that I have said a proper
plaster of paris jacket. Plaster of paris bandages
wound about the patient's body in an indifferent
manner are not a *,oper jacket.

We would here like to mention the colitis that
frequently accompanies tubercular disease of the
spine and hips. Frequently after an Albee or a
Hibbs operation more pain is complained of from
cramping of the bowels than from the operation.
Much stringy mucus will be passed and until the
bowel is relieved of this the patient will be very
uncomfortable.  An emulsion of kerosene I oz.,
olive oil 6 oz., allowed. to flow gently into the
bowel with low rectal tube, seems more efficient
than anything else in clearing up the colitis as
well as relieving the pain. The quantity given
above is for an adult.

A WATER-BORNE TYPHOID FEVER EPI-
          DEMIC.*

By WILBGR A. SAWYER. M. D.. Dlrertor of the Hyplrnlc
Laboratory of the Callfomla State Board of Health.
The city of Healdsburg in Sonoma County, Cali-
fornia, was almost entirely free from typhoid fever
for a number of years -prior to the- summer of
IOIA. Between Tulv 15 and Scotember 22 of that
year'the city was"&ited by an e'pidemic of typhoid
fever consisting of ninety reported cases and seven
deaths.

Eighty of the persons affected resided in Hea&
burg, and eight on near-by farms.  One lived in
Oakland, and one in Petaluma. All received their
infection in Healdsburg.  How many travelers

o Read before the Alnmrdfl County Medlral Asaorlntlon,
Anrll 20. 1915.


196        CALIFORNIA STATE JOURNAL OF MEDICINE  Vol. XIII, No. 5

contracted the disease and became sick in. distant
cities is a matter Of c0njecture.
As there were sewn deaths among the ninety
cases recognized as a part of this epidemic, the
mortality was 7.8%. One of the deaths occurred
on a farm near Healdsburs The OakIan'd patient
died in a San Francisco hospitaI. `The five ~tha
dea'ths occurred among the eighty residing in
Healdsburg.

made a field study of the epidemic, gathering data
from physicians and patients, studying the water
supply, investigating suspected sources of pollu-,
tion of the Russian River as far north as Clover-
dale, and advising the city authorities regarding
emewencv measures of control.  In this work I was

Healdsburg has an estimated population of 2100
persons.  Excluding from consideratitin the incorn-
plete reports of oases outside the city, we have the
folIowing statistics for the eighty cases (including
five deaths) among residents of the city.
The cases' were 3.8% of the population, .or in
the ratio of 3810 per IOO,OOO people.  The deaths
were 0.24% of the population, or 2jS pair 100,000
People. The case mortality wan 6.3%.
The. distribution of cases among patients of vari-
c&s ages departs but little from the usual arrange-
ment as. determined by the United States Public
Health Service in a recent study of the available
statistics.' The cases of the Healdaurg epidemic
have been arranged according to the e of the
patients in Table I.
Tabtc I-Ages of th&~~~Fever Patients by
ADS" I," ;y.        Numbers of Patients.

    11 to 20        :;
  3: :: ii        iii
    41 to 50                  8
8; :: 2 ,        s:
     -.

Total 3 to 66          90
In 64 of the QO cases of typhoid feirer the

diagnosis was confirmed by a positive mitioscopic
agglutination. test. In If cases the agglutination
test was negative, but most of the samples of blood
failing to give a positive reaction were taken early
in the disease. In only three cases were negative
results obtained from blood drawn over nine days
after the onset. All but two of the Widal tats
were made in the State Hygienic Laboratory. In
nine cases samples' of blood were not submitted for
examination.  Sixteen additional cases were re-
ported but were shown by investigation or later
developmctits to be probably not typhoid fever.

The severity of the cases, as in most typhoid
fever epidemics,' varied within wide limits. One
patient in whom the diagnosis was determined by
a positive Widal reaciion was in bed only four
days. As a prolonged and intensive investigation
of this epidemic was not possible, a number of the
lighter cases probabIy escaped attention. There
were many severe cases, and among the complica-
tions reported were relapses, bronchitis, pneumonia,
convulsions, hemorrhages from the bowels, and
perforation of the intestines.

THE IVESTIGATION. I

In response to a request from Dr. J. W. Sea-
well, Health Officer of Healdsburg, the California
State Board of Health instructed me on August- I
to go to Healdsburg and co-operate with the au-
thorities there in finding out the source of the out-
break of typhoid fever.  From August z to 6 I

greaiiy assisted by the vigorous co-operation of. Dr.
J. W. Seawell, Health Of&r; Mr. C. R Nelson,
Suocrintcndent
--r-m ~~~~~~~  of the Municipal Watrt and Elcc-
tric Light Plants; Mayor A. F. Stevens; and the
physicians of Healdsburg.

The source of infection was found to be the city
water supply.- The city water had been used by
all whose cases were investigated, including those
persons who resided in the country. The milk
suppfy, on the other hand, came from many sources,
including several dairies. Some of the patients
were suodied from nciehborhood cows. Others
used canned milk, and o'ne used only goat's milk.
There were no veeetable or food SUDDkS nor
eating placea common to the majority ii the pa-
tients. The case against the city water was
fur@er strengthened by the fact that a sample
of the water had bein sent by a city oflicial to
the State Hygienic L&oratory on May 5, 1914,
and colon bacilli had been isoIated from amounts
of the water as small as one cubic centimeter.
A modqrate pollution with intestinal bacteria was,
therefore, demonstrable at least two months be-
fore the epidemic began. If the State Board of
Health had had in its employ a sanitary engineer
to make the field investigation neces&y to de-
termine the full sienificance of the labaratorv find-
ings, he could th& have demonstrated to th; IocaI
officials the need for immediate treatment of the
water supply, and the epidemic might have been
prevented and seven lives saved.
: The course of the epidemic is shown in the
accompanying chart. The number of cases begin-
ning on each day is shown by the height of the
shaded area. Light shading indicates that the pa-
tient recovered, and dark shading denotes a fatal
termination.  The characteristics of a water-borne
typhoid fever epidemic, as contrasted with a milk-
borne or food-borne epidemic, are shown by the
gradual beginning and prolonged course. To em-
phasize this contrast, this water-borne epidemic is
compared in the chart with the recent food-borne
typhoid fever outbreak in Hanford, California.*
The former began gradually and was prolonged,
because the infectious material was supplied through
a.long period of time, while the Hanford epidemic
began suddenly and was brief, since it was due to
infection from a single dish of food. In the for-
mer, a very small proportion, probably about five
per cent., of the people who repeatedly drank the
moderately polluted water came down with typhoid
fever, while in the latter 57 per cent. of those who
ate the highly infected food developed the disease.
In epidemics due to g sudden, severe, and brief
infection of a drinking water supplp the outbreak
may be exDIosive. like a tvnical food-borne eni-
demic, but ;he Hkaldsburg &tbreak represents ;he
more usual type of water-borne epidemic.
Some of the Iate cases in the Healdsburg epi-
demic were probably infected from the earlier cases


MAY, rgr+   CALIFORNIA STATE JOURNAL OF MEDICINE           197

. instead of directly from the city water.  This  The parts pf town which received the least water
would accotint for most of the cases in the small  through the supposedly infected pipes had their full
group at the end of the epidemic.        share of cases. Moreover, at the time of the field
About the middle of July, when the epidemic WAS  investigation the daily number of new cases was
beginning, there weremany cases of diarrhea among  increasing, although over three weeks had elapsed
the people of Healdsburg, according to the rcgarts  since the last pipe was laid.  The epidemic was
of several of `the. physicians.  It is not uncommon  evidently not due to sewage accidentally admitted
for cases of diarrhea to `accompany or preI;defi;  to the new pip&
water-borne ebidemic of typhoid fever.

water-borne typhoid epidemic at Rockford, Illinois,         THE WATER SUPPLY.
a city of 30,000 people, about 10,000' cases of   The Healdsburg water supply is pumped from
entiritis axxmd kween ,-January 16 --and ~0,  five wells situated a short distance above the city
19x2, and this outbreak was followed by rgg cases  in the bed of the Russian River. The wells are
of typhoid fever having their onsets between Janu-  in that portion of the wide river bed which is sub-
ary 23 and February 29.8 Many Rockford pea-, merged only during high water. Three of the
ple had both diseases.              wells, I, 2, and 3, were bored to depths of 54, 34

l4&KR- BORNE MPHOlD FEVER EPIDEMIC

   AT ~HEALDSBUR~, SONOHA Co.

          CORtRA8lzD wlM

FOOD - BORNE T'YRHOID ,FtVER  EPIDEMIC

  I    JIW     (MT& Of olwrrJ     AlqUW   tuu.               o ?????????       ?
It was suspected by some of the physicians that  and' 36 feet respectively. They were 20 ~I&S ii;
the diarrhea and the earlier cases of typhoid fever
in the Healdsburg epidemic were due to the acci-  diameter and had been sealed at the top with
dental inclusion of sewage in some new water  cement to prevent the entrance of river water

mains.  Some 1500 feet of new cast-iron pipe were  during freshets. Well No. 4, the one nearest the
laid in certain streets of Healdsburg, mostly in  river, is an old dug well with a brick curb, and is
the business district, between June 23 and July  ten feet in diameter and between 25 and 30 feet

IO.  .9t one point a disconnected house-drain was  deep.  A wooden cover bolted in place was in-
said to have been seen discharging into a ditch  tended to prevent the entrance of river water. This
which had been dug to receive the pipes. The  well is 42 yards (measured by pacing) from the
contractor who laid the pipes denied the possibility  edge of the water in the river at the summer
of the inclusion of sewage. No cases of typhoid  level. Well No. 5 is a large dug well situated
fev r antedating the epidemic had come to the at-  near well No. 4 and almost as near to the river.
ter ;on of the physicians of Healdsburg, and the  This well is 12 feet in diameter and 40 feet deep,
IaLrers who dug the ditches and laid the pipes  and is protected by a wooden cover.  All five of
wert all local men who were apparently well.  the wells were sunk into the gravel' and sand of


CALIF'ORNIA STATE JOURNAL OF MEDICIME  Vol. XIII, No. 5

the river bed without encountering any! hpentious
strata.

`IIU pipes fmm the five well5 are all connected
and it is impossible to tell how much water COCKS
from cwh. From the pumping station the water
goes to two reservoir5 on a hill 122 feet higher
than Healdsburg. Their combined capacity is said
to be ~oo,ooo gallons. The wells are reported to
furnish between ~OO,OOO and 600,000 gallons a day.
On August 3rd and 4th sample5 were taken at
the surface of the water in each of the two dug
wells, at the surface of the water in each Mer-
voir, from the pipe carrying the mixed water of
the five wells from the pumping station, from a
faucet in the center of the city, and also from the
Russian River opposite the wells. These samples
were backed in ice and atnt to the State Hygienic
Laboratory for bacteriological examination.
Af the laboratory it was found that the total
number of bacteria in the samples from -the two
dug wells and from the pipe carrying the mixed
water from .the five wells was app&xilnnteIy half
the number found in tbe samples from the river
opposite tbt wells. The bacterial count of tbe
water in' the reservoirs exceeded that of the river.
water, and the bacteria in the water collected in
rh &:r were five time5 as numerous a5 those in '
       .
Tbeoe.variations werti due. largely to water bac-
teria and were not so important to the invati-
gation as were estimates of the .numbers of in-
testinal bacteria, represented by the colon bacillus.
In the river water colon bacilli were isolated from
amounts of the water as small as one cubic ccnti-
meter, but not from 0.1, cc. In well No. 4. they
were found in 3.0 cc and not in 1.0 cc.  In well
No. 5 they were not found in 3.0, c.c., although
bacteria producing gas in glocose medium were
demonstrated in LO C.C. of the water. In the
sample from the mixed water of all the wells colon
bacilli `were found in 3.0 CC but not in 1.0 c.c.,
and in each reservoir they were found in 5.0 cc
but not in 3.0 cc Iri the sample from a faucet
in the city, takin August qth, colon bacilli were iso-
lated from 1.0 C.C. and not from 0.x a, a result
tbe+ame a5 that for the sample in the R&an
River and for `the .sample previously taken from
the distributing system on May 5, 1914, The
samples taken where the .water was kept agitated,
as in the river and in, the pipes above the pump-
ing station and in Healdsburg, as a rule showed
a number of colon bacilli which was greater than
where the water was quiet and undergoing sedi-
mentation, as at the surfaces of the reservoirs and
of the dug wells when the pumps were not run-
ning. When the pump5 are in operation, a large
part of the water enters the distributing system
without pa5sing through the reservoin, and there
is, therefore, little purification by sedimentation be-
tween the wells and the consu&r.
In brief. the laboratorv examinations showed that

the water' in the river *was polluted with sewage
and was not appreciably purified by passing through
at least 42 yards. of gravel and the city water
system. The.polldt'ion in the river was about qua1
to that in the distributing system of the city. In

each instance colon bacilli were demonstrated in *
1.0 cc of the water but not in 0.1 C.C. The
bame grade of pollution had been demonstrated Cfi
the water previous to the appearance of typhoid
$.:-<"3P. r. 5, ?ri May r: ,. Y9I4.
In' order to c&&ete the demonstration that
the city water came from the Russian River, sam-
pies were taken from a faucet in the city .a.nd from
the river and sent for chemical analysis to Profes-
sor M. E. jaffi, Director of the State Food and
Drug Laboratory. The report5 of the analyses
were almost identical, and Professor Jaffa stated
in the letter with his report, "It would appeti
from the enclosed data that these waters are prac-
tically dram the same source."

THE POLLUTION OF THE RIVER.

Many towns and the city of Ukiah are situatrd
on the R&an River above Healdsburg, . and some
sewage pollution, coming from many sources, would
be expected. The principal communities as far up'
the river as Cloverdale were visited and their
sewage systems investigated, without discovering
evidence bearing directly on the epidemic. The
bank5 of the river in the vicinity of Healdsburg
w&e carefully studied. About a mile above the
city wells a sewer from a summer resc)rt was found
discharging fecal matter into a part of the river
freely used for boating and swimming. The outlet
wsis concealed by a dense growth of willows and
was discovered only by entering the ~thicket in a
boat. There had been no case of typhoid fever at
the building,from which the sewage came, but a
typhoid convalescent or a chronic typhoid carrier
may have been among the summer guests or serv-
ant?r. Some connection between the epidemic ar;d
the summer guests is probable, because the height
of the season for the summer resorts was early
in July, just before the epidemic began. The re-
sort whose untreated sewage was found flowing
irito the river had only six guests at the time of
the investigation, but had had over a hundred early
in July.

A grave responsibility rests with the physician
who sends a convalescent from typhoid fever to a
summer resort without first asccitaining whether
the sewage from the resort is properly disposed of,
or at least warning the local health officer so that
he can investieate.

At the time of greatest population in the camps
and taverns along the river it is orobable &at the
sewage pollution`was greater than at the time of
the investigation.  A number of cottaKes have

cesspools in the bed of the river where the water
can quickly drain through the foose sand and gravel
and pollute the stream.

So long a5 the Russian River is used extensively
for boating and swimming, the pollution of the
river by the entrance of raw sewage, the untreated
effluent from septic tanks, and the seepage from
cesspools situated in the river bed should SC pro-
hibited. Otherwise typhoid fever and other water-
borne diseases must be expected.
        fh?WACE DISPOSAL.

The sewage of a city in which typhoid fever is
prevalent is a source of danger. The Healdsburg
sewage passes through a septic tank and is then


MAY, .Igrl, .: -, _ CALIFORNIA STATE JOURNAL OF MEDICINE            199

conveyed to Dry Creek, which empties into the
Russian River several miles below HeaIdsburg.
Inspection of the creek stied a condition typical
of many of our California water-courses in sum-
mer. There was a wide gravelly creek-bed through
which flowed a small stream, sometimes rippling
over the &ones, ,often concealed under the gravel
for' twenty yards or more, and occasionally stand-
ing in shallow pools.  ,A. sample of watei was
taken from a pool xg7 yards below the sewer oult-
let. The water had flowed through three pools for
a total of 150 yards and throu& two stretches
of eravel for 47 vards. Colon bacilli were iso-
l&z from o.o&y c:c. of the water, which was not
tested in ,smaller amounts. Such a test demon-
strata only the facts+ well known to sanitary
engineera, that tlwseptic tank cannot be depended
upon to remove colon bacilli from sewage, and that
the same. can be said regarding rapid percolation
through loose gravel. Investigations of septic tank8
under favorable conditions have shown that the
contetit of intestinal bacteria; as indicated hy the
number of colon bacilli, is not greatly reduced
when the sewage' passes through a beptic tank.'
Likewise, typhoid bacilli and many other patho-
genic organisms can' survive the septic tank, a~ the
conditions are not sufficiently unfavorable to bring
about their destruction. The'function of the septic
tank, whether it be of the Cameron type, of the
Imhoff type, or of any other variety, i.9 to reduce
the amount of suspended solids hy sedimentation
and putrefaction of the sediment under anaerobic
conditions. The effluent from the tank is about as
dangerous as the same sewage without treatment,
but owing to the decrease iti putrescible solids, it
becomes less of a nuisance. The eeluent should
undergo further treatment if it is to enter a stream
which is used, unpurified, for drinking purposes.

The flowing of polluted streami through the
gravel of their beds, under the summer conditions
exemplified in Dry Cmk, does not purify the
water, and the drinking of water. from the pools
or "springs," as they are sometimes called, is dan-
gerous.  It is obvious thar water running rapidly
through gravel, either from a river to shalloi wells
or in the bed of a stream, does `not allow a suf-
ficient time factor to insure adequate filtration.
Both the rapidity of flow and the coarseness of the
material are such that sufficient purification by
filtration is not effected.

The epidemic of 350 cases of typhoid fever at
Centralia, Washington, in December, 1913, and
January, 19x4, was caused, like the Healdsburg
epidemic, by taking water from wells sunk into
the gravel at the edge of a klluted river.' The
water had to pass through at least twenty feet of
gravel.  The percentage of the population in-
volved (3.5%) and .the case mortality (6.5%)
were almost the same as the corresponding figures
for the Healdsburg epidemic
     CONTROL OF THE EPIDEMIC.
Prior to the investigation, Dr. Seawell, City

Health Officer. of Healdsburg, suspected the city
water supply as' the source of the infection and in-
stl,Icted the people, through a local newspaper,

to boil ail drinking water, to protect food from
flies, and to avoid the eating of raw vegetables.
The uublic was slow to heed this advice. and one
of the principal hotels continued to serve- raw city
water until. specially warned.

When the source of infection had been deter-
mined, recommendation was made to the city au-
thorities that &be city water be treated with hypo-
chlorite as an emergency measure. An extempo-
rized plant for introducing hypochlorite at the
    .
pumpmg stat& was set G;P u&r the direction 31
Professor -FT. S. Griswold of the University of
California and was operated by lOC2.l mCR, b+l-
ning on August 7th. Six days rafter the treatme:::
began, extiination showed that colon bacilli could
still be demonstrated in 1.0 C.C. of the water, al-
though the total bacterial `count had. fallen from
6oo to 20 per cc. The amount of hypochlorite
was then increased. Twenty days after the treat-
ment began the local authorities sent another sam-
ple, which showed that the water was entirely
safe. The bacterial count was I per cc. and colon
bacilli were absent in IO cc.

The new cases continued to be reported in con-
siderable number for twenty days after the first
application of the hypochlorite treatment, but after
that there were onIy scattered cases, probably secon-
dary to earlier cases.

In order to reduce the number of new infections
from the city water and from the earlier cases, rhe
physicians administered typhoid vaccine to many
persons. The State Hygienic Laboratory issued to
Healdsburg physicians, between July 28 and Sep-
tember 4, vaccine for immunizing 642 people, and
most of It was undoubtedlv administered. The
vaccine used was the sensi&cd typhoid vaccine
manufactured in accorda'nce with the method of
Gay and Claypole and issued free to physicians of
California. The vaccine was given in three doses
at intervals of two or three days, thus permitting
the complete treatment to be adminiStered in five
days instead of in twenty-one days, as is required
by the usual methods.  Two persons developed
typhoid fever between tlie first and last dose. On!y
one suspected cast of typhoid fever was reported
among those for whom vaccination was completed.
A man who received his three doses of vaccine on
August 5, 7 and 12, became sick on December 13,
nearIy three months after the last case of the epi-
demic, complaining of headache and backache and
swelling of the eyelids. He had a moderate fever
which had fallen to normal on December 29. A
diagnosis of abortive typhoid fever was made bJ
the attending physician. A positive Widal reaction
was obtained, but it may have been entirely due
to the vaccination.  Unfortunately the case came
under the observation of his physician too late for
a blood culture to be of value.  Among the un-
vaccinated there w&e 41 cases subsequent to Au-
gust 6, a date sufficiently late to permit the-earliest
patients to have received three doses of vaccine.

     SUMMARY AND CONCLUSIONS.
I. The Healdsburg epidemic of go cases, inclu-
ding seven deaths, was caused by polluted water
which passPd from the Russian River through at


CALIFORNIA

least 42 yards' of gravel to the wells
watt?+ system

2. Rapid straining `through coarse

STATE JOURNAL OF MEDICINE  Vol. XIII, No. 3

of the city

gravel and

sand, either naturaiIy through the beds of our dry
creeks, or from a contaminated stream to wells,
cannot be depended upon adquately to purify pal-
luted water.
3. Septic tanks do not free sewage from typhoid
bacilli and other pathogenic organisms, and their
untreated e5luent.s may seriously contaminate a
stream.

4 As long as the Russian River is used exten-
sively for boating and swimming, it should be pro-
tected from the entrance of raw sewage, the un-
treated efRuent of septic tanks, and the seepage
from cesspooIs situated in the river bed. '
3.  Inasmuch as every typhoid fever epidemic in-
creases the amount of the disease in distant parts
of the state and in future generations, and since
the question of the water supply and sewage dis-
posal of each community necessarily involves more
than the one community, it is the dut$ of the state
to. examine all public water supplies and sewage
disposal systems at frequent intervals and to pre-
vent, the use for drinking purposes of dangerously
polluted water. Sanitary engineers in the state's
empIoy are needed for carrying on this work.
They are needed, also, to look after engineering
aspects of the investigation of water-borne epidem-
ics `like the one in Healdsburg, and to aid in emer-
gency measures for their control.
1 P&llC HWth. Re rts. U. 8.
Fsb 1~1616 XXX. g. 6 ,634-636. Public Health Service.

Typhol darrlsr at (L Pub110 Dlnner. Jour. Am
ri er iK. A.: Nlndv-three Pomona Infected b do
                   J
Anbc., Oct. Xl. lDl4, LXIII, 1sa7-1643.
6 JorAan, EAwln 0.. MA Iron& Emcat Rl.: The Rcck-
t%a,%, 9 hoIA Epldsmlc Jour. of Infectlow Dla-
       1 13 Vol XI. No 1 51-43