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 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