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NoTE:-The last line shows the number of cases using any given water supply. counted more than once in the upper (numbered) lines.

The figures above show the combinations in which each was used and the frequency of

each combination. As a result many sources are

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statement were children, the credibility of this assertion is very questionable. In two instances there was strong probability of contact being the source of infection. It is not impossible, of course, that this well, as well as others in the city, would receive from time to time a sufficient number of typhoid organisms to produce an occasional case, but that this well was responsible for all the typhoid that occurred amongst its users is hardly to be believed. The remaining wells, as will be seen from the table, were used so infrequently as to necessitate no comment. The cases not to be accounted for by the Second avenue and Thirteenth street well are attributed to the city water supply, despite the fact that only 44 of the remaining 100 cases admitted drinking this water. With few exceptions, the water was used in cooking, washing utensils, and in many instances for toilet purposes, including brushing the teeth, and there is much doubt as to the accuracy of the statement in many instances that the water was not actually used for drinking. Ordinarily one might doubt the possibility of an explosive outbreak through such limited use of the water. IIowever, it is conceivable that utensils used as milk containers in the home rinsed with a highly infected water would serve as a source of infection of the milk and this after a period of incubation would contain large numbers of organisms and become a medium infective even in small quantities. The number of cases that were discovered as having their Onset during the month of August among persons not using the water from the Second avenue and Thirteenth street well is significant, taken in conjunction with the fact that the city began pumping water from the Hudson on July 24. Among all the cases discovered in the investigation, but one of them gave an onset before August 6, and the Health Department records showed but five cases other than these during the months of June and July. As milk and other sources could be satisfactorily ruled . out, this sudden general increase in the number of cases throughout the city, impels one to the belief that the water supply was the source of infection. The use of city water was unquestionably much greater than that indicated by the replies given the investi

gators. The reasons for considering the city water as a contemporary source of infection may be summarized in the following: 1 The increase in the number of cases beginning twelve days after the installation of the pump on Broadway between Fifteenth and Sixteenth streets. 2 The highly polluted source from which this water was derived and the insufficient chlorination it received. 3 The fact that sewage was constantly becoming more and more highly infected by cases occurring in the Second avenue and Thirteenth street district. 4. The varied number of other sources from which the cases obtained their drinking water. 5 In the investigation conducted by Doctor Meader in 1916, the use of the city water for drinking purposes was denied in a large percentage of instances and at that time the cases occurred in that section of the city nearest the pumping station. This year after the pumping station was moved further north, the cases occurred further north. 6 The character of the population — largely foreigners and careless in their hygienic habits — leads one to doubt the statements of non-use in many instances. 7 The fact that the water was so highly polluted and, as time went on, undoubtedly, was so highly infected with typhoid that it was not even necessary to drink it in order to contract the disease. The use of a highly infected water for washing cooking utensils can produce typhoid fever. In viewing this outbreak as a whole, it is quite apparent that much suffering and a number of deaths could have been prevented had the beginnings of this outbreak been noted and prompt measures taken to suppress the possible sources of infection. Of the 35 cases occurring in August, 14 were entirely unreported and 15 were reported from three to five weeks after the date of onset. It is recognized that the physicians are not entirely responsible for these late reports, as in some cases a physician was not consulted until two weeks or more after the date of earliest symptoms. However, in a number of these cases and in those entirely unreported this was solely the result of negligence on the part of the physicians to perform their duty. The fact that some cases were diagnosed as other than typhoid fever hardly seems a fair excuse, inasmuch as no adequate attempt was made to diagnose the cases by the laboratory methods at their disposal. Twenty-seven per cent of the cases investigated were unreported by the physician and had to be discovered by other methods. It was also found that in but very few instances would the other members of the family be immunized against typhoid fever, owing to a lack of appreciation of the benefits of this measure by the public and the failure of the physicians to urge it. The records show that there were twenty-one houses in which two cases each occurred and three houses in which three cases occurred. In one instance there were five cases in one house. A study of the dates of onset shows that there were nineteen probable and six positive secondary cases. In most instances, of course, the secondary cases were exposed to the same sources of infection as the primary cases, but in the above are included as probable secondary cases only those giving dates of Onset ten days or more after the primary cases. Universal vaccination of exposures would undoubtedly have decreased the number of secondary cases which is excessively high. It probably would have been higher except for the fact that a considerable number of cases were hospitalized and but for the services of the Metropolitan nurse who visited the homes of many of the poorer cases and gave instructions in the proper precautions to be observed. In the course of the investigation we learned of eight cases occurring among the boarders at a popular boarding house. Two of these cases were among residents of Troy who work in Watervliet and had their luncheons at this boarding house. Three had their illness after leaving Watervliet for other places, one in Kingston, one in Rutland, Vermont, and one in Conneaut, Ohio. In the three cases occurring in Watervliet, two used water from the Second avenue and Thirteenth street well and the third drank city water. One of these cases using the Second avenue and Thirteenth street well, a Mrs. B., was employed as a cook in this boarding house, beginning the latter part of July or

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