moved from the table with pulse 108 and in good shape. Appendix much thickened and contained a fecalith.

Convalescence was uninterrupted, and on Dec. 4, 1903, she wrote to me that she was in the best of health and entirely free from pain and indigestion.

Pathological Anatomy.-The appendix will be found, in a large per cent. of chronically inflamed appendices, greatly thickened. This is due to stricture of the organ, which excites tenesmus, this in time giving rise to muscular hypertrophy. If the stricture is absolute there results a varying degree of distension, a somewhat remarkable case of which I recorded in the American Journal of Obstetrics, Vol. XII, No. 1.

Perforation and peritonitis may follow distension. If the stricture is not absolute, effort of the organ to empty itself will give rise to recurring attacks of pain, with nausea and indigestion. There is not infrequently found so-called appendicitis obliterans, which is characterized by progressive obliteration of the lumen of the appendix. In 400 post-mortems where death was due to causes other than appendicitis, Ribbert found complete obliteration in 25 per cent. In a series of 232 cases Zuckerkandl found the lumen obliterated in 23.7 per

cent.

Bacteriology. The bacillus coli communis is found in nearly all cases of appendicitis, acute or chronic. In 24 cases recorded by Hodgenpgl there were only two cases associated with other forms of bacilli-one with the bacillus pyogenes fetidus and one with the streptococcus. In two of my acute cases in which bacteriologic examinations were made I found with the bacillus coli communis, streptococcic infection. One of the cases recovered and the other terminated fatally. The proteus vulgaris is also not infrequently met with. I have also met with two cases of tubercular appendicitis in which was found the tubercle bacillus. Latent micro-organisms in the thickened appendicular walls are undoubtedly responsible for the recurrent attacks of inflammation. Re-infection probably takes place through some abrasion of the mucous membrane.

816 Rose Building.

One occasionally sees a fracture of the skull in which after the lapse of a week or ten days the patient has so far recovered that he is inclined to get out of bed and pursue his ordinary occupation. This should be resisted, for it is never safe to allow these patients to stay in bed less than three or four weeks.

SOME ASPECTS OF FILTRATION.

By Joe C. Beardsley, Assistant Engineer, Cleveland Water Works.

The filtration of public water supplies may be divided into two general classes: slow sand filtration, which is the common method abroad and "mechanical" filtration, in which some sort of coagulant is used and which is the more common practice in this country.

In the former, after sedimentation in settling basins, the water is passed through a layer of fine sand and one of gravel to a drain underneath, through which it is conveyed to the pumps.

Preliminary sedimentation is absolutely necessary only with turbid river waters, and in the case of lake and pond waters might be dispensed with entirely, though in most cases these basins would be very desirable for storage purposes; its object is to get rid of the coarser matter held in suspension, thus diminishing the frequency with which it is necessary to clean the filters. The finer suspended matter is then filtered out by the sand, forming in the process a layer on the surface of the latter, which in turn becomes a filter even better than the sand itself, owing to the much smaller size of the particles. It will thus be observed that the efficiency of a sand filter increases as this layer becomes thicker until a point is reached where it is impossible to force through the required amount of water; it then becomes necessary to remove this layer of sediment, which is done by scraping, the water meanwhile being turned on another filter bed. This layer of sediment should not be allowed to reach a thickness of more than one inch before cleaning. Experience shows that this method eliminates not only any organic suspended matter, but also a very large percentage of the bacteria, an efficiency of 99 per cent. having been reported from the Albany plant. The rate of filtration in this method is from two to three million gallons per acre per 24 hours. At this rate, Cleveland, with a maximum consumption of one hundred million (100,000,000) gallons for 24 hours, would require filter beds. covering from thirty (30) to fifty (50) acres.

This method has only been used to a limited extent in this country, the plant at Albany and the uncompleted one at Washington being the most notable examples. The second method, commonly called "mechanical," makes use of a coagulant, usually sulphate of alumina. When this is added to the water it is decomposed into its component parts, sulphuric acid and alumina, the latter in the form of a precipitate which attracts to itself the suspended matter in the water, including bacteria, thus allowing of their easy removal by filtration.

The sulphuric acid combines with any other base that may be

present as lime, or, if none be present, remains in the water as free acid and perhaps partly in its original condition. It follows that if there is enough of the free acid to cause an acid reaction the effluent from the filter is unfit for use and incidentally is very destructive to iron pipes. Very careful handling by experts, therefore, is necessary with this method to avoid serious disturbances. Other coagulants which have been used are lime, ferrous and ferric compounds, notably ferric sulphate and metallic iron; this last is known as Anderson's process. The area necessary for a mechanical filter plant is much less than for sand filtration. As applied to Cleveland, no detailed figures of cost are available, as no examination of conditions has been made. Supt. Bemis, of the Water Works Department, roughly estimates the cost of a "mechanical" filtration plant at two million dollars, based on the cost of similar plants elsewhere and assuming that the plant can be located on the present grounds of the Kirtland St. Pumping Station. This would involve a considerable re-arrangement of the present pumping plant and an entirely new plant would be necessary to pump water into the filters. It is likely that additional ground would either have to be purchased adjoining the present grounds or would have to be made in the lake. The annual expense of this plant would probably be about three hundred thousand dollars (300,000), to meet which the present rates would likely have to be raised about one-third (%). The cost of a sand filtration plant would probably be about three million five hundred thousand ($3,500,000) dollars, but might exceed four million ($4,000,000). The Washington plant, with a capacity of 75,000,000 gallons in 24 hours, has had an appropriation up to the present time of $3,468,405, and this may or may not be enough to finish it. The Washington plant covers an area of thirty-four (34) acres. The maintenance charge for a sand filtration plant would probably not be so very much greater than with "mechanical" filtration, since the cost of operation would be somewhat less. In Washington it is estimated that this charge would be six ($6.00) dollars per million gallons. Considerable stress has been laid from the advantage to be gained in being speedily able to put a filtration plant in use, two years being the limit in which it is estimated that one could be put in operation. This might be realized should the contracts be let at once and nothing there happen to interfere with the rapidity of construction. It is doubtful, however, if the preliminary examinations and reports could be made in less than a year and it might take six months longer to decide on the type of filter to be used. In Washington the first act of Congress in connection with the filter project was passed June 30th, 1898, the engi

neers' report was submitted March 28th, 1900, and was in favor of "mechanical" filtration; this evidently precipitated trouble, and during the summer of 1900 it was apparently not "all quiet on the Potomac." The following is quoted from the report of the engineer in charge of the work: "At the examination of experts by the Senate Committee and the hearing before the House Sub-Committee, a strong opposition to the use of any chemical as coagulant in any process of filtering the Washington water supply was manifested by the resolutions of the Washington Board of Trade, Washington Business Men's Association and the Medical Society of the District of Columbia. The result of this agitation was, that on March 1st, 1901, $500,000 was appropriated toward establishing a slow sand filtration plant." At Louisville proposals on a 75,000,000 gallon plant were received January 26th, 1901, and as yet this plant is not completed or in operation. At Little Falls, New Jersey, a 50,000,000 gallon mechanical filter was built by the East Jersey Water Co. in two years and four months, counting from the time at which the preliminary report was filed. In both of these cases (Louisville and Little Falls) the work has been done by private corporations and it is notorious that a municipality cannot begin to compete in point of rapidity of operations with such corporations. In Philadelphia the first appropriation for filtration was made in June, 1898. The first filtered water was derived from this plant on August 12th, 1902, and on December 1st, 1902, the daily output was 8,000,000 gallons. The ultimate capacity of the Philadelphia plant is to be 300,000,000 gallons per day. It is somewhat interesting to note that every one of these cities derives its water supply from a river flowing through a comparatively densely populated area, resulting in serious pollution. None of the larger lake cities have taken any serious steps toward filtration. Ashland, Wisconsin and Lorain, Ohio, have filtration plants, the former sand and the latter "mechanical."

The former is on a confined, shallow bay, which is badly polluted by sewage, and a turbid river brings down at times a great deal of sediment. At Lorain the intake is only a short distance to the west of the mouth of the river and being only 1,800 feet from shore, is only just outside the pier heads. As all of the sewage of both Lorain and Elyria goes into the Black river, it is not difficult to understand why filtration is necessary at Lorain. It is curious to note that there has been considerable complaint relative to the taste of the water in Lorain at various times, this being due, I presume, to an excess of free acid or undecomposed sulphate in the water.

The method which Cleveland and some other lake cities have

chosen of overcoming the pollution problem was by extending tunnels that would be beyond the limits of sewage contamination; this, together with a scheme of intercepting sewers, that would carry all the sewage to one point far to the east of the new intake, was the result of long and careful study by three of the most eminent water works and sanitary specialists in the country. We are only just now realizing a part of their scheme in the completion of the water works tunnel, from which the total water supply will be received by the city by the time the frost is out of the ground. In this connection it is interesting to note that the decline in the number of typhoid fever reports has followed very closely the increase in the pumpage from the Kirtland St. Pumping Station.

Strenuous efforts have been made in the press, and elsewhere, to cast suspicion on the water from the new intake, but careful bacteriological examinations made at intervals since January 1st last, by Mr. Geo. C. Whipple, of New York, fail to discover any trace of sewage contamination and I may say that if they fail to show now, no fear as to the future may be had, for the combinations of conditions will probably never again be so thoroughly unfavorable as it was at the time of the February thaw, when with an unprecedented amount of ice in the lake, an unprecedented quantity of sludge was washed out of the river, followed almost immediately by the shifting of the wind to the north, which brought the ice back to the south shore within a few hours, thus completely confining the objectionable matter which had been brought down by the river, and preventing its oxidation.

In conclusion I wish to make the following statement showing the relation of typhoid fever cases to water meters.

From February 1st to March 4th inclusive, 665 cases of typhoid fever were reported; of this number 220 occurred where the services were metered, 256 unmetered, and 186 were at places for which there was no record on our books and 3 were outside the city limits.

"PRE-NATAL INFLUENCES."

By D. C. Kline, M. D., Reading, Pa.

By pre-natal influences, we mean anything and everything that may occur to affect the mental, moral or physical well-being of the child during the period of pregnancy, i. e., from the moment of conception to the hour of birth; influences set in operation prior to conception would come under the term heredity: and those after birth would be occurrences of childhood.