Cleveland Medical and Surgical Reporter. Contributions are solicited upon any subject connected with the practice of medicine or the allied sciences, and the only restrictions placed upon them are that they shall be free from personalities and given to the REPORTER exclusively. The Editor of the REPORTER is not responsible for any opinion expressed by contributors. Vol. XIII. MARCH, 1905. No. 3. Original Articles. THE WATER SUPPLY OF CITIES. By Galus J. Jones, M. D., Professor Theory and Practice of Medicine, Man cannot live on bread alone, but he can live a long time on bread and water, and he can live longer on water alone than he can on bread. Next to pure air, pure water, is the most essential thing for humanity. The larger the city, the more difficulties lie in the way of securing pure water. The smaller towns depend upon wells chiefly for their water supply. In some instances it is procured from springs which come to the surface of the earth, and running water of this character is not uncommonly seen in some of the small villages of the country. Occasionally wells are sunk deeply into the ground, from which water flows in a continuous stream (artesian wells). The large towns chiefly depend upon running streams which are dammed up for the purpose of accumulating a body of water, and this is held in reserve and allowed to be carried to the town in a systematic manner. Many of the large cities of this country are located upon the shore of large bodies of fresh water and the water supply is pumped from such lakes into the pipes which supply the city. It is a very difficult matter to obtain pure water in the first place, and to prevent its becoming contaminated later. The cities themselves are responsible for much of this contamination, for in most instances the waste products-the sewage-of such cities are allowed to flow into the lake from whence water is secured. Many diseases are produced by such contamination. Typhoid fever is the disease which is most commonly produced in this way and we judge of the pollution of the water to a considerable extent by the number of cases of typhoid fever which prevail in such cities. Besides the typhoid bacillus, the bacillus coli communis is found very frequently. I quote from Dibdin (Purification of Sewage and Water): "The presence of the bacillus coli communis in water was for merly held to indicate direct sewage contamination. It is now known that this organism may be derived from many sources, such as the excreta from horses and other animals, so that its presence in waters collected from gathering grounds is practically universal and unless they are present in unduly large numbers, accompanied by other bacteria, such as the bacillus euteritides sporogenes and streptococci, little notice need be taken of them, otherwise no water supply of this nature could be admitted as sufficiently pure for potable purposes. In the case of waters from deep wells it is held by some, however, that the presence of even one or two bacilli coli communis indicates so suspicious a condition of affairs that such waters should be either filtered or subjected to treatment by Clark's softening process, in order to afford a further defence against sudden contamination, should such occur, by reason of the breakdown of fissures, etc. "In this connection bacteriology has been in the transition stage. At first, large numbers of bacteria of any kind were held to indicate pollution. Then it was assumed that the presence of bacillus coli communis in any numbers indicated danger. Next it was admitted that these might be present in limited numbers in surface waters, unless they were accompanied by others of a suspicious character. Further experience has shown that during periods of heavy rainfall, when the water level in the ground rises and the water has consequently a less degree of filtration through the ground before it reaches the well, the bacillus coli communis and its allied forms will occasionally be present. The fact that, under these circumstances, the total quantity of chlorine in the water will frequently be diminished, clearly indicates that the source of pollution, if it can be properly so called, cannot be due to ordinary sewage contamination. In all these cases it is most important that the history of the water should be clearly ascertained, as it is evidently improper to impute serious contamination to a water when the variations are due to ordinary causes and in no way to human excremental causes. "Now and then one meets with reports in which some new form of bacterium is mentioned, with the remark that 'in the present state of our knowledge the importance to be attached to the presence of this organism is uncertain.' Such sensationalism is to be most strongly deprecated. Bacteriology has done yoeman service, and requires no such bolstering as this to frighten public authorities into spending money on further bacteriological examinations, which, unless controlled by chemical examinations and a complete knowledge of the facts, are apt, as in the past, to create needless apprehension." In cities which lie on the seashore, one of the favorite methods of disposing of sewage, when possible, is its discharge into sea-water, on the assumption that the enormous dilution effected would speedily bring about its disintegration and destruction. I quote again from Dibdin: "This is one of those cases in which the maxim 'out of sight, out of mind' was thought to have special application; and, in consequence, the universally considered panacea for the sewage difficulty at seaside towns was to run an outfall sewer as far as convenient out into the sea and to discharge the sewage at such time of the tide as was thought would effectually carry it away. The result, however, in many cases has not been all that was desired. In some instances the flow of the tide has brought the sewage back to the point of departure, and in some cases right into the stretch of water used for bathing, so that visitors have had to postpone their 'dip' until the unsightly flood has drifted further on. Not only has this objectionable feature been the result of the system, but in one instance I have in mind a large ventilating shaft on the outfall sewer has been erected on the beach, with a series of steps leading right up to the top, with the result that this made an excellent 'coign of vantage' for children who climbed up to the top and sat on the grating, thus mixing their seaside breeze with the emanations from the sewage below them. The result of this elementary method of disposal, however, is now known not to cease here. In a large number of instances the sewage discharged finds its way to various oyster, mussel, or cockle beds, and it is now well established that the effect of this has been to cause typhoid fever in many of those who have partaken of such infected food." In this connection I cannot do better than to quote from a report made in 1903 by a committee from the Cleveland Homeopathic Medical Society, of which the writer was a member, and whose chairman, Dr. W. T. Miller, was the president of our State Board of Health: "The consideration of a few remarkable epidemics will go far towards showing the relations between the disease and contaminated water supply. At Lausanne, Switzerland, an outbreak of typhoid fever occurred among that portion of the population which derived its drinking water from a certain spring. On the other side of the hill was a brook which passed underground and it was suspected that this brook really fed the spring in question. When flour was added to the brook water, however, none of it made its appearance in the spring. but when salt was dissolved in the stream its presence was soon afterwards discovered in the spring. Obviously, the water in traversing this hill became so filtered as to completely remove all the particles of the flour, yet such filtration had failed to remove the typhoid bacillus, which it was proved had been introduced into the brook by patients suffering from that disease. Shortly after the fouling of the stream, typhoid fever broke out amongst those who used the spring water, sixty-seven persons being attacked within ten days. In Massachusetts it was found that the highest typhoid death rates were not in the cities, but in the towns supplied by well water. The introduction of pure water supplies had in all cases been followed by a decrease in the typhoid mortality, but in the two cities, Lowell and Lawrence, with a population of 123,000, there were during the previous twelve months about one-third more deaths than in the city of Boston with four times the population. The cause of this excessive prevalence of typhoid fever was investigated, and it was found that prior to the outbreak the Lowell water supply had been contaminated by the fæces discharged into Stony Brook only three miles above the intake of the water works. This pollution was followed in about three weeks by a very rapid increase in the number of deaths from typhoid fever in Lowell, and about six days later by a larger increase in the number of deaths in Lawrence, whose water supply is drawn from the Merrimac River, nine miles from the point at which the Lowell sewage enters the river. An examination of the water of the service pipes of Lawrence led to the discovery of the typhoid bacillus therein. In the Tees Valley epidemic it was found that forty-eight persons in ten thousand using the Tees water were attacked with typhoid fever and only three among persons supplied with water supplied from other sources. In the second epidemic the attack rates were twenty-eight and one respectively. The Tees water, therefore, was greatly contaminated and its source was fully examined. It was found that either directly or indirectly, the drainage from twenty hamlets, as well as that of the town of Barnard Castle, poured into the river above the intake of the Water Company. The recent fatal epidemic of the disease at Ithaca, New York, where it was found that the water supply was contaminated by the fæces from laborers working along the banks of the river, is evidence fresh to your minds of the baleful influence of contaminated water. The Local Situation. Our city of 381,666 people, situated on the southern shore of Lake Erie at the mouth of the Cuyahoga River, has its intake water pipe one and one-third miles from the shore, and onehalf mile west from the mouth of the River. The prevailing currents of the lake at this point are eastward, yet a south wind will frequently drive the water near the shore in a westerly direction, so that the sewage from the river will travel at times towards the intake. Our sewage system is a combined sanitary and storm water system with numerous The outlets into the river along the shore of the lake east and west. chief sewer on the west side, that of Waverly Avenue, empties into the harbor east of the west arm of the breakwater. This was found to create a nuisance, that part of the harbor forming a vast settling basin or septic tank, in which the sewage underwent putrefactive changes and gave rise to noxious odors. The west arm of the breakwater was opened to the extent of two hundred feet and now there is a movement of the current from the mouth of the Waverly Avenue sewer through the break in the harbor wall westward in the direction of the intake pipe at the rate of about thirty feet per minute, as shown by the driftwood on the surface, so that in a few hours after the sewage is discharged at the foot of Waverly Avenue it is taken into the intake pipe and distributed throughout the city for drinking purposes. The history of typhoid fever in the city for the last five years shows deaths in 1893, 121; in 1899, 119; in 1900, 205; in 1901, 140; in 1902, 136; in 1903, from January first to March twentieth, 86, a total mortality in five years of 906. This mortality based upon eight per cent. fatality, using therefore a multiple of 1212, would be 11,225 cases during the past five years. The most convincing chemical evidence of water contamination is the amount of chlorine which is liberated by the putrefaction of organic matter. The chemical analysis of our city water during the past fifteen years, as made by Professor Smith, of Case School, shows a very marked progressive increase in the amount of chlorine, as shown by the following table: Parts per million, spring of 1887, 2.8; 1888, 2.8; 1889, 3.3; 1890, 4.3; 1891, 5.9; 1892, 5.8; 1893, 6.0; 1894, 6.6; 1895, 7.5; 1896, 7.4; 1897, 8.0; 1898, 8.3; 1899, 8.8; 1900, 9.3; 1901, 10.5; March, 1902, 12.2; Dec., 1902, 11.7. Repeated microscopical examination of the water during a series. of years has shown a constant presence of intestinal bacteria. This is evidence sufficient to prove the dangerous contamination of the water by sewage. The remedy now being provided is the extension of the water works intake pipe out beyond the supposed area of sewage contamination and the completion of the intercepting sewer which will collect the sewage and deliver it at a point ten miles eastward. While this will remove the danger to a large degree, it is the opinion of your committee that it will not guarantee the people a pure water supply. It is therefore recommended by your committee that the city appoint a Water Commissioner to proceed at once to the consideration of plans for the purification by filtration of the water, and that meanwhile the |