Chapter XIV Water-Supply and Disease — Conclusions
One of the most characteristic and uniform results of the direct pollution of public water-supplies is the typhoid fever which results among the users of the water. In the English and German cities with almost uniformly good drinking-water, typhoid fever is already nearly exterminated, and is decreasing from year to year. American cities having unpolluted water-supplies have comparatively few deaths from this cause, although the figures never go so low as in Europe, perhaps on account of the fresh cases which are always coming in from less healthy neighborhoods in ever-moving American communities. In other American cities the death-rates from typhoid fever are many times what they ought to be and what they actually are in other cities, and the rates in various places, and in the same place at different times, bear in general a close relation to the extent of the pollution of the drinking-water. The power of suitable filtration to protect a city from typhoid fever is amply shown by the very low death-rates from this cause in London, Berlin, Breslau, and large numbers of other cities drawing their raw water from sources more contaminated than those of any but the very worst American supplies, and by the marked and great reductions in the typhoid-fever death rates which have followed at once the installation of filters at Zürich, Switzerland; Hamburg, Germany; Lawrence, Mass., and other places.
The following is a list of the cities of 50,000 inhabitants and upward in the United States, with deaths from typhoid fever and the sources of their water-supplies. The deaths and populations are from the U. S. Census for 1890; the sources of the water-supplies, from the American Water-Works Manual for the same year. Four cities of this size—Grand Rapids, Lincoln, St. Joseph, and Des Moines—are not included in the census returns of mortality. Two cities with less than 50,000 inhabitants with exceptionally high death-rates have been included, and at the foot of the list are given corresponding data for some large European cities for 1893.
| TYPHOID FEVER DEATH-RATES AND WATER-SUPPLIES OF CITIES. | |||||
|---|---|---|---|---|---|
| City. | Population. | Deaths from Typhoid Fever. | Water-supply. | ||
| Total. | Per 100,000 living. | ||||
| Birmingham | 26,178 | 69 | 264 | Five Mile Creek | |
| 1. | Denver | 106,713 | 232 | 217 | North Platte River and wells |
| 2. | Allegheny | 105,287 | 192 | 182 | Allegheny River |
| 3. | Camden | 58,313 | 77 | 132 | Delaware River |
| 4. | Pittsburg | 238,617 | 304 | 127 | Allegheny and Monongahela rivers |
| Lawrence | 44,654 | 54 | 121 | Merrimac River | |
| 5. | Newark | 181,830 | 181 | 100 | Passaic River |
| 6. | Charleston | 54,955 | 54 | 98 | Artesian wells yielding 1,600,000 gallons daily |
| 7. | Washington | 230,392 | 200 | 87 | Potomac River |
| 8. | Lowell | 77,696 | 64 | 82 | Merrimac River |
| 9. | Jersey City | 163,003 | 134 | 82 | Passaic River |
| 10. | Louisville | 161,129 | 122 | 76 | Ohio River |
| 11. | Philadelphia | 1,046,964 | 770 | 74 | Delaware and Schuylkill rivers |
| 12. | Chicago | 1,099,850 | 794 | 72 | Lake Michigan |
| 13. | Atlanta | 65,533 | 47 | 72 | South River |
| 14. | Albany | 94,923 | 67 | 71 | Hudson River |
| 15. | Wilmington | 61,431 | 43 | 70 | Brandywine Creek |
| 16. | St. Paul | 133,156 | 92 | 69 | Lakes |
| 17. | Troy | 60,956 | 42 | 69 | Hudson River and impounding reservoirs |
| 18. | Los Angeles | 50,395 | 34 | 67 | Los Angeles River and springs |
| 19. | Nashville | 76,168 | 49 | 64 | Cumberland River |
| 20. | Cleveland | 261,353 | 164 | 63 | Lake Erie |
| 21. | Richmond | 81,388 | 50 | 61 | James River |
| 22. | Hartford | 53,230 | 32 | 60 | Connecticut River and impounding reservoir |
| 23. | Fall River | 74,398 | 44 | 59 | Watupa Lake |
| 24. | Minneapolis | 164,738 | 94 | 57 | Mississippi River |
| 25. | San Francisco | 298,997 | 166 | 56 | Lobus Creek, Lake Merced, and mountain streams |
| 26. | Indianapolis | 105,436 | 57 | 54 | White River |
| 27. | Cincinnati | 296,908 | 151 | 51 | Ohio River |
| 28. | Memphis | 64,495 | 33 | 51 | Artesian Wells |
| 29. | Reading | 58,661 | 29 | 49 | Maiden Creek and Springs |
| 30. | Baltimore | 434,439 | 202 | 47 | Impounding reservoir |
| 31. | Omaha | 140,452 | 63 | 45 | Missouri River |
| 32. | Columbus | 88,150 | 38 | 43 | Surface-water and wells |
| 33. | Providence | 132,146 | 53 | 40 | Pawtuxet River |
| 34. | Kansas City | 132,716 | 53 | 40 | Missouri River |
| 35. | Rochester | 133,896 | 53 | 39 | Hemlock and Candice lakes |
| 36. | Evansville | 50,756 | 20 | 39 | Ohio River |
| 37. | Boston | 448,477 | 174 | 39 | Impounding reservoirs |
| 38. | Toledo | 81,434 | 29 | 36 | Maumee River |
| 39. | Cambridge | 70,028 | 24 | 34 | Impounding reservoir |
| 40. | St. Louis | 451,770 | 145 | 32 | Mississippi River |
| 41. | Scranton | 75,215 | 24 | 32 | Impounding reservoir |
| 42. | Buffalo | 255,664 | 80 | 31 | Niagara River |
| 43. | Milwaukee | 204,468 | 61 | 30 | Lake Michigan |
| 44. | New Haven | 81,298 | 22 | 27 | Impounding reservoir |
| 45. | Worcester | 84,655 | 22 | 26 | Impounding reservoir |
| 46. | Paterson | 78,347 | 20 | 26 | Passaic River (higher up) |
| 47. | Dayton | 61,220 | 15 | 25 | Wells |
| 48. | Brooklyn | 806,343 | 194 | 24 | Wells, ponds, and impounding reservoirs |
| 49. | New York | 1,515,301 | 348 | 23 | Impounding reservoir |
| 50. | Syracuse | 88,143 | 18 | 20 | Impounding reservoir and springs |
| 51. | New Orleans | 242,039 | 45 | 19 | Mississippi River |
| 52. | Detroit | 205,876 | 40 | 19 | Detroit River |
| 53. | Lynn | 55,727 | 9 | 16 | Impounding reservoir |
| 54. | Trenton | 57,458 | 9 | 16 | Delaware River |
| London | 4,306,411 | 719 | 17 | Filtered Thames and Lea rivers and 1⁄4 from wells | |
| Glasgow | 667,883 | 138 | 20 | Loch Katrine | |
| Paris | 2,424,705 | 609 | 25 | Spring water | |
| Amsterdam | 437,892 | 69 | 16 | Filtered dune-water | |
| Rotterdam | 222,233 | 12 | 5 | Filtered Maas River | |
| Hague | 169,828 | 3 | 2 | Filtered dune-water | |
| Berlin | 1,714,938 | 161 | 9 | Filtered Havel and Spree rivers | |
| Hamburg | 634,878 | 115 | 18 | Filtered Elbe River | |
| Breslau | 353,551 | 37 | 11 | Filtered Oder River | |
| Dresden | 308,930 | 14 | 5 | Ground-water | |
| Vienna | 1,435,931 | 104 | 7 | Spring-water | |
Any full discussion of these data would require intimate acquaintances with the various local conditions which it is impossible to take up in detail here, but some of the leading facts cannot fail to be instructive.
Each of the places having over 100 deaths per 100,000 from typhoid fever used unfiltered river-water. Lower in the list, but still very high, Charleston, said to have been supplied only from artesian wells, had an excessive rate; but the reported water-consumption is so low as to suggest that private wells or other means of supply were in common use. Chicago and Cleveland both drew their water from lakes where they were contaminated by their own sewage. St. Paul’s supply came from ponds, of which I do not know the character. With these exceptions all of the 22 cities with over 50,000 inhabitants, at the head of the list, had unfiltered river-water.
The cities supplied from impounding reservoirs as a rule had lower death rates and are at the lower end of the list, together with some cities taking their water supplies from rivers or lakes at points where they were subject to only smaller or more remote infection. Only three of the American cities in the list were reported as being supplied entirely with ground-water.
It is not my purpose to make too close comparisons between the various cities on the list; some of them may have been influenced by unusual local conditions in 1890. Others have in one way or another improved their water-supplies since that date, and there are several cities in which I know the present typhoid-fever death-rates to be materially lower than those of 1890 given in the table. On the other hand, it is equally true that a number of cities, including some of the larger ones, have since had severe epidemics of typhoid fever which have given very much higher rates than those for 1890.
These fluctuations would change the order of cities in the list from year to year; they would not change the general facts, which are as true to-day as they were in 1890. Nearly all of the great cities of the United States are supplied with unfiltered surface-waters, and a great majority of the waters are taken from rivers and lakes at points where they are polluted by sewage. The death-rates from typhoid fever in those cities, whether they are compared with better supplied cities of this country, or with European cities, are enormously high.
Such rates were formerly common in European cities, but they have disappeared with better sanitary conditions. The introduction of filters has often worked marvellous changes in Europe, and in Lawrence the improvement in the city’s health with filtered water was prompt and unquestionable. There is every reason to believe that the general introduction of better water in American cities will work corresponding revolutions; and looking at it from a merely money standpoint, the value of the lives and the saving of the expenses of sickness will pay handsomely when compared with the cost of good water.
The reasons for believing that cholera is caused by polluted water are entirely similar to those in the case of typhoid fever. It was no accident that the epidemic of cholera which caused the death of 3400 persons followed the temporary supply of unfiltered water by the East London Water Company in 1866, while the rest of London remained nearly free, or that the only serious outbreak of cholera in Western Europe in 1892 was at Hamburg, which was also the only city in Germany which used raw river-water. This latter caused the sickness of 20,000 and the death of over 8000 people within a month, and an amount of suffering and financial loss, with the panics which resulted, that cannot be estimated, but that exceeded many times the cost of the filters which have since been put in operation. Hamburg had several times before suffered severely from cholera, and the removal of this danger was a leading, although not the sole, motive for the construction of filters.
How little cities supplied with pure water have to dread from cholera is shown by the experience of Altona and other suburbs of Hamburg with good water-supplies, which had but few cases of cholera not directly brought from the latter place, and by the experience of England, which maintained uninterrupted commercial intercourse with the plague-stricken city, absolutely without quarantine, and, notwithstanding a few cases which were directly imported, the disease gained no foothold in England.
I do not know of a single modern European instance where a city with a good water-supply not directly infected by sewage has suffered severely from cholera. I shall leave to others more familiar with the facts the discussion of what happened before the introduction of modern sanitary methods, as well as of the present conditions in Asia; although I believe that in these cases also there is plenty of evidence as to the part water plays in the spread of the disease.
A considerable proportion of the water-supplies of the cities of the United States are so polluted that in case cholera should gain a foothold upon our shores we have no ground for hoping for the favorable experience of the English cities rather than the plague of Hamburg in 1892.
The fæces from a man contain on an average perhaps 1,000,000,000 bacteria per gram,47 most of them being the normal bacilli of the intestines, Bacillus coli communis. Assuming that a man discharges 200 grams or about 7 ounces of fæces daily, this would give 200,000,000,000 bacteria discharged daily per person. The number of bacteria actually found in American sewage is usually higher, often double this number per person; but there are other sources of bacteria in sewage, and in addition growths or the reverse may take place in the sewers, according to circumstances.
This number of bacteria in sewage is so enormously large that the addition of the sewage from a village or city to even a large river is capable of affecting its entire bacterial composition. Thus taking the population of Lowell in 1892 at 85,000, and the average daily flow of the Merrimac at 6000 cubic feet per second, and assuming that 200,000,000,000 bacteria are discharged daily in the sewage from each person, they would increase the number in the river by 1160 per cubic centimeter, or about 300,000 in an ordinary glass of water. The average number found in the water eight miles below, at the intake of the Lawrence water-works, was more than six times as great as this, due in part to the sewage of other cities higher up.
There is every reason to believe that the bulk of these bacteria were harmless to the people of Lawrence, who drank them; but some of them were not. Fæces of people suffering from typhoid fever contain the germs of that disease. What proportion of the total number of bacteria in such fæces are injurious is not known; but assuming that one fourth only of the total number are typhoid germs, and supposing the fæces of one man to be evenly mixed with the whole daily average flow of the river, it would put one typhoid germ into every glass of water at the Lawrence intake, and at low water several times as many proportionately would be added. This gives some conception of the dilution required to make a polluted water safe.
One often hears of the growth of disease-germs in water, but as far as the northern United States and Europe are concerned there is no evidence whatever that this ever takes place. There are harmless forms of bacteria which are capable of growing upon less food than the disease-germs require and they often multiply in badly-polluted waters. Typhoid-fever germs live for a longer or shorter period, and finally die without growth. The few laboratory experiments which have seemed to show an increase of typhoid germs in water have been made under conditions so widely different from those of natural watercourses that they have no value.48
The proportionate number of cases of typhoid fever among the users of a polluted water varies with the number of typhoid germs in the water. Excessive pollution causes severe epidemics or continued high death-rates according as the infection is continued or intermittent. Slight infection causes relatively few cases of fever. Pittsburg and Allegheny, taking their water-supplies from below the outlets of some of their own sewers, have suffered severely (103.2 and 127.4 deaths from typhoid fever annually per 100,000, respectively, from 1888 to 1892). Wheeling, W. Va., with similar conditions in 1890, was even worse, a death rate of 345 per 100,000 from this cause being reported, while Albany had only comparatively mild epidemics from the less directly and grossly polluted Hudson. Lawrence and Lowell, taking their water from the Merrimac, both had for many years continued excessive rates, increasing gradually with increasing pollution; and the city having the most polluted source had the higher rate.
In Berlin and Altona, in winter, with open filters, epidemics of typhoid fever followed decreased efficiency of filtration, but the epidemics were often so mild that they would have entirely escaped observation under present American conditions. Chicago has for years suffered from typhoid fever, and the rate has fluctuated, as far as reliable information can be obtained, with the fluctuations in the pollution of the lake water. An unusual discharge of the Chicago River results in a higher death-rate. Abandoning the shore inlet near the mouth of the Chicago River in 1892, resulted in the following year in a reduction of 60 per cent in the typhoid fever death-rate.49 This reduction shows, not that the present intakes are safe, but simply that they are less polluted than the old ones to an extent measured by the reduction in the death-rate.
It is not supposed that in an epidemic of typhoid fever caused by polluted water every single person contracts the disease directly by drinking the water. On the contrary, typhoid fever is often communicated in other ways. If we have in the first place a thousand cases in a city caused directly by the water, they will be followed by a large number of other cases resulting directly from the presence in the city of the first thousand cases. The conditions favoring this spread may vary in different wards, resulting in considerable local variations in the death-rates. Some persons also will suffer who did not drink any tap-water. These facts, always noted in epidemics, afford no ground for refusing to believe, in the presence of direct evidence, that the water was the cause of the fever. These additional cases are the indirect if not the direct result of the water. The broad fact that cities with polluted water-supplies as a rule have high typhoid-fever death-rates, and cities with good water-supplies do not (except in the occasional cases of milk epidemics, or where they are overrun by cases contracted in neighboring cities with bad water, as is the case with some of Chicago’s suburbs), is at once the best evidence of the damage from bad water and measure of its extent.
The conditions which remove or destroy the sewage bacteria in a water tend to make it safe. The most important of them are: (1) dilution; (2) time, allowing the bacteria to die (sunlight may aid in this process, although effective sunshine cannot reach the lower layer of turbid waters or through ice); (3) sedimentation, allowing them to go to the bottom, where they eventually die; and (4) natural or artificial filtration. In rivers, distance is mainly useful in affording time, and also, under some conditions, in allowing opportunities for sedimentation. Thus a distance of 500 miles requires a week for water travelling three miles an hour to pass, and will allow very important changes to take place. The old theory that water purifies itself in running a certain distance has no adequate foundation as far as bacteria are concerned. Some purification takes place with the time involved in the passage, but its extent has been greatly overestimated.
The time required for the bacteria to die simply from natural causes is considerable; certainly not less than three or four weeks can be depended upon with any confidence. In storage reservoirs this action is often considerable, and it is for this reason that American water-supplies from large storage reservoirs are, as a rule, much more healthy than those drawn from rivers or polluted lakes, even when the sources of the former are somewhat polluted. The water-supplies of New York and Boston may be cited as examples. In many other water-works operations the entire time from the pollution to the consumption of the water is but a few days or even less, and time does not materially improve water in this period.
Sedimentation removes bacteria only slowly, as might be expected from their exceedingly small size; and in addition their specific gravity probably is but slightly greater than that of water. The Lawrence reservoir, holding from 10 to 14 days’ supply, effected, by the combined effect of time and sedimentation, a reduction of 90 per cent of the bacteria in the raw water. In spite of this the city suffered severely and continuously from fever. It would probably have suffered even more, however, had it not been for this reduction. Nothing is known of the removal of bacteria by sedimentation from flowing rivers, but, considering the slowness with which the process takes place in standing water, it is evident that we cannot hope for very much in streams, and especially rapid streams, where the opportunities for sedimentation are still less favorable.
Filtration as practiced in Europe removes promptly and certainly a very large proportion of the bacteria—probably, under all proper conditions, over 99 per cent, and is thus much more effective in purification than even weeks of storage or long flows in rivers. The places using filtered water have, in general, extremely low death-rates from typhoid fever. The fever which has occurred at a few places drawing their raw water from greatly polluted sources has resulted from improper conditions which can be avoided, and affords no ground for doubt of the efficiency of properly conducted filtration.
Corresponding evidence has not yet been produced in connection with the mechanical filters which have been largely used in the United States; but the bacterial efficiencies secured with them, under proper conditions, and with enough coagulant, have been such as to warrant the belief that they also will serve to greatly diminish the danger from such infection, although they have not shown themselves equal in this respect to sand filters.
The main point is that disease-germs shall not be present in our drinking-water. If they can be kept out in the first place at reasonable expense, that is the thing to do. Innocence is better than repentance. If they cannot be kept out, we must take them out afterwards; it does not matter much how this is done, so long as the work is thorough. Sedimentation and storage may accomplish much, but their action is too slow and often uncertain. Filtration properly carried out removes bacteria promptly and thoroughly and at a reasonable expense.
APPENDICES.