Chapter I: Typhus and Other Continued Fevers (10)

In the last quarter of 1846, the deaths from fever in London had been 619. In all England, the last quarter of 1846 was also most unhealthy, its deaths from all causes being 53,055 (only 43,850 in the first quarter of the year). The summer of 1846 had been remarkable for heat and drought, and the end of the year was, according to precedent, an unwholesome time. It was just the season for enteric fever, as in the still more memorable circumstances of 1826. There is evidence from various parts of England and Scotland that much of the fever of the end of 1846 was enteric; and it was doubtless the unusual prevalence of that disease, and of other maladies that are favoured, like it, by extreme fluctuations of the ground-water, that explains the very high mortality of the last quarter of 1846[390]. But it is equally certain that it was typhus which raised the fever deaths in London in the last quarter of 1847 to 1,279, and the deaths from all causes in all England to the enormous total of 57,925. In the whole of the year 1847, typhus alone claimed 30,320 deaths in England and Wales, the total in 1848 falling to 21,406. Lancashire and Cheshire had the largest share of this epidemic, and Liverpool the largest share in Lancashire. In that Registration Division (the North-western) the deaths from typhus in 1847 were 9,076, and in 1848 they were 3,380. Next in order (excluding London and suburbs) came the West Midland Division, and next to that Yorkshire. At Liverpool, and in other places of the north-west of England, the fever was very clearly connected with the enormous Irish immigration, and was in great part among the Irish. There were floating lazarettos on the Mersey, filled with fever and dysentery, workhouses overflowing, and sheds hastily built to hold each 300 patients. The following returns from the several sub-divisions of Liverpool for the months of July, August and September, 1847, show the proportions of dysentery and fever, as well as the mortality from diarrhoea, which last was mostly an affair of the infants and young children[391]:

_Liverpool deaths, July-Sept. 1847._

Fever Dysentery Diarrhoea
St Martin’s 291 82 174
Dale Street 250 20 111
St Thomas (301 deaths on the floating lazarettos)
Mount Pleasant 324 18 73
Islington 105 37 78
Great Howard Street (the fever extending to the upper classes)

In his report for the quarter before (April, May and June, 1847) the registrar of the Great Howard Street sub-district says: “Eight Roman Catholic priests, and one clergyman of the Church of England, have fallen victims to their indefatigable attentions to the poor of their church[392].”

In Manchester there were causes of fever independently of the Irish contagion. The registrar of the Deangate sub-district writes in the third quarter of 1847: “In the calamitous season just passed, manufactures have been almost at a stand-still; food has been unattainable by the poor, for employment they had none; Famine made her dwelling in their homes &c.” The hardships of the children caused an immense mortality from summer diarrhoea. The same registrar gives an account of the epidemic fever in his report for the second quarter of 1847, from which it appears that, although nearly all the hospital cases were distinctly maculated, and the fever was undoubtedly typhus in all other respects and in its conditions, yet tympanitis, with abdominal tenderness and diarrhoea, were specially noted[393].

Besides Liverpool and Manchester, many other towns in Lancashire had the “Irish fever” in them; also Birmingham, Dudley, Wolverhampton, Shrewsbury, Leeds, Hull, York and Sunderland. Except in London, the fever mortality was not unusual in the southern half of England[394].

In Scotland the epidemic was a mixture of relapsing fever and typhus. The following were the proportions of each admitted to the Glasgow Royal Infirmary:

Year Relapsing Fever Typhus

1846 777 500
1847 2,333 2,399
1848 513 980
1849 168 342

In the Barony Fever Hospital, Glasgow, open from 5 August 1847 to July 1848, the relapsing cases were double the typhus cases at the opening of the hospital, at the end of 1847 they were nearly equal, and from February 1848 the typhus cases were double the relapsing. In Edinburgh, where the epidemic was less severe, the same relations were observed--relapsing fever most at the beginning, typhus fever (much more fatal) most at the end[395]. Some relapsing fever occurred also in London, among destitute Irish, which was often attended by a miliary eruption (Ormerod).

Subsequent Epidemics of Typhus and Relapsing Fevers.

By midsummer, 1848, there was a most marked improvement in the public health, corresponding with the great fall in the prices of food, under the influence of free trade, and with a good harvest and the commencement of an era of steady employment for workers. The improvement is strikingly shown in the following comparison of the deaths from all causes in Lancashire and Cheshire in the third quarter of each of the years 1846, 1847 and 1848:

1846 1847 1848

Deaths in the 3rd Quarter 15,221 17,080 11,720

Since the epidemic of 1847, which was not unfairly called “the Irish fever,” there has been no such extensive and fatal outbreak of typhus or relapsing fever in England, Scotland or Ireland. The fever deaths rose somewhat in Ireland and in Glasgow in 1851-53, the type of disease being relapsing and typhus. In London there was a considerable increase of typhus in 1856, at the end of the Crimean War. From 1861 to 1867 there was a considerable epidemic of the same fever in England and Scotland (not much of it in Ireland until 1864), the chief centres in England having been the Lancashire towns, Preston, Manchester, Accrington, Chorley, Salford and Blackburn, and the occasion of it the “cotton famine” of the American Civil War[396]. Greenock was the chief seat of typhus in 1863-64 in Scotland; indeed, in the whole kingdom, its death-rate from that cause was approached by that of Liverpool only. Fevers had been very mortal there in the epidemic of 1847 (it is said 353 deaths); in the next fever-period they rose as follows[397]:

1860 1861 1862 1863 1864

19 57 63 98 274

This epidemic was more easily dealt with than those of the same kind before it. Very large sums were subscribed by the wealthy, of which, indeed, a considerable balance remained undistributed. Rawlinson, as engineer, and Villiers, as Minister, devised extensive relief works, in the form of main drainage for the distressed Lancashire towns, the whole cost being defrayed eventually by the municipalities themselves. The following table, from Murchison, shows the admissions for typhus to the fever hospitals of various towns, subsequently to the great epidemic of 1847-48. The first rise in London was in 1856; the next rise, which was somewhat prolonged, coincided with the epidemic in Lancashire.

_Hospital Cases of Typhus, 1849-71._

London Edin. Glasgow Glasgow Dundee Aberdeen Cork
Fever Royal Royal Fever Royal Royal Fever
Year Hosp. Infirm. Infirm. Hosp. Infirm. Infirm. Hosp.

1849 155 -- 342 -- -- -- --
1850 130 -- 382 -- -- -- --
1851 68 -- 919 -- -- -- --
1852 204 -- 1293 -- -- -- --
1853 408 -- 1551 -- -- -- --
1854 337 -- 760 -- -- -- --
1855 342 -- 385 -- -- -- --
1856 1062 -- 385 -- -- -- --
1857 274 -- 314 -- -- -- --
1858 15 -- 175 -- 17 -- --
1859 48 -- 175 -- 128 -- --
1860 25 -- 229 -- 67 -- --
1861 86 -- 509 -- 129 -- 116
1862 1827 14 780 -- 54 -- 272
1863 1309 74 1286 -- 236 379 (4 mos.) 692
1864 2493 212 2150 -- 264 811 1021
1865 1950 447 2334 1154 891 422 791
1866 1760 847 1055 384 706 167 247
1867 1396 303 761 795 225 68 124
1868 1964 280 620 1023 502 78 245
1869 1259 259 1430 2023 402 170 136
1870 631 287 947 702 232 61 165
1871 411 101 418 511 257 3 397

During the unusual prevalence of fever in Scotland, 1863-65, it was made clear by the diagnosis in hospitals, that the excess was caused by typhus, and not by enteric.

Of 440 cases of fever treated in the Royal Infirmary of Edinburgh, in
1864, 212 were cases of pure typhus, 140 were enteric fevers, while 88
were simple continued fever and febricula. In the Royal Infirmary of
Glasgow in 1864, of 2,190 cases of fever, 2,150 were reported to be
cases of typhus fever, while only 40 were cases of enteric fever. In
the Aberdeen Royal Infirmary not a case of enteric fever was observed:
of 396 cases in the year 1863, 387 were pure typhus, and 9 febricula;
and in 1864, of 926 cases, 897 were pure typhus and 29 febricula. In
the Royal Infirmary of Dundee, of 355 cases of fever treated in 1864,
318 were typhus, 16 enteric fever, and 21 febricula. It was only at
Perth, and there not exclusively in hospital practice, that an excess
of typhoid fever was observed; from 1st August, 1863, to 30th April,
1864 (months which included the special typhoid season), there were
101 cases of gastro-enteric or typhoid fever, 46 cases of typhus, 19
of relapsing fever, and 59 of simple continued fever[398].

The last considerable prevalence of contagious fever in England and Scotland was in 1869 and 1870. It was relapsing fever, mixed with some typhus, and it was restricted almost to a few large towns, including London, Liverpool, Manchester, Leeds, Bradford, Glasgow, and Edinburgh[399]. It was first seen in London in 1868 among Polish Jews. It was heard of as late as 1872 at Newcastle. It was observed during this epidemic in Liverpool, Bradford and Edinburgh that the subjects of the relapsing fever were not suffering from want[400]. The same observation has been made in some foreign countries. Still, on the great scale and in a broad view, relapsing fever has been _typhus famelicus_ or famine-fever, occurring in association with other maladies due to want, and especially in the circumstances which have been discussed fully in the chapter on fevers in Ireland.

Relative prevalence of Typhus and Enteric Fevers since 1869.

It was not until the year 1869, or about the time when typhus fever ceased to be epidemic or common, that the deaths from typhus fever, simple continued fever and enteric fever began to be tabulated separately in the Registrar-General’s reports. The following tables show for England and Wales and for London a steady decline of the deaths from typhus and simple continued fever since the end of the epidemic period 1869-71, which was the last epidemic of typhus and relapsing fever in this country hitherto. The deaths from enteric fever, it will be seen, remained somewhat steady (in a growing population) for about ten years after the separation, and then began to decline.

_Continued-fever Deaths in England and Wales, 1869-91._

Simple or
Year Typhus Ill-defined Enteric

1869 4281 5310 8659
1870 3297 5254 8731
1871 2754 4248 8461
1872 1864 3352 8741
1873 1638 3081 8793
1874 1762 3089 8861
1875 1499 2599 8913
1876 1192 1974 7550
1877 1104 1923 6879
1878 906 1776 7652
1879 533 1472 5860
1880 530 1490 6710
1881 552 1159 5529
1882 940 1016 6036
1883 877 963 6068
1884 328 768 6380
1885 318 662 4765
1886 245 505 5061
1887 211 502 5165
1888 168 436 4848
1889 140 413 4971
1890 160 361 6146
1891 148 325 5075

_Continued-fever Deaths in London, 1869-91._

Simple or
Year Typhus Ill-defined Enteric

1869 716 615 1069
1870 472 570 976
1871 384 436 871
1872 174 322 867
1873 277 325 968
1874 312 337 879
1875 128 272 817
1876 159 202 769
1877 157 194 901
1878 151 197 1033
1879 71 160 849
1880 74 134 702
1881 92 134 971
1882 53 95 975
1883 55 102 963
1884 32 75 925
1885 28 78 597
1886 13 73 618
1887 19 44 612
1888 9 35 694
1889 16 42 538
1890 10 35 604
1891 11 44 557

Such being the proportions of typhus and enteric fever since 1869, when the separation was made, it remains to ask what share each of them may have had in the total of “typhus,” or of continued fever generally, in the years before the two forms were distinguished in the annual registration reports. Of course, they were distinguished by many of the profession long before that; so that there are means of forming a judgment. At the London Fever Hospital, enteric fever and typhus were distinguished after 1849. If the admissions of each kind of fever to that hospital be assumed to have been proportionate to the prevalence of each in London from year to year, we should get in the following table a means of estimating which of the two forms of continued fever furnished most of the deaths in all London, as given in the first column:

Admissions to London
Deaths in Fever Hospital
London from
Year both fevers Typhus Typhoid

1838 4078 -- --
1839 1819 -- --
1840 1262 -- --
1841 1151 -- --
1842 1184 -- --
1843 2094 -- --
1844 1721 -- --
1845 1324 -- --
1846 1838 -- --
1847 3297 -- --
1848 3685 -- --
1849 2564 155 138
1850 2032 130 137
1851 2374 68 234
1852 2183 204 140
1853 2617 408 212
1854 2816 337 228
1855 2410 342 217
1856 2717 1062 149
1857 2195 274 214
1858 1919 15 180
1859 1840 48 176
1860 1476 25 95
1861 1848 86 161
1862 3673 1827 220
1863 2871 1309 174
1864 3782 2493 253
1865 3217 1950 523
1866 2688 1760 582
1867 2184 1396 380
1868 2468 1964 459

From this it will appear that every great annual rise in the London deaths from “fever,” since the last great typhus epidemic of 1847-48, has corresponded to a greatly increased admission, not of enteric cases, but of typhus cases into the London Fever Hospital. On the other hand, enteric fever has been at a somewhat steady or endemic level for a good many years. Even at that level it would have had a small share of the whole fever-mortality in the old London; in modern London, especially in its residential quarters, its rate has probably been higher than in former times; while in recent years, owing to the absolute decline of typhus, it has been by far the most common continued fever. If the conditions were the same in London as in Edinburgh, it was the very creation of residential streets and new quarters of the town that called forth typhoid fever; while the more the town was remodelled, the more were the _fomites_ of typhus destroyed. Thus it seems probable that the same progress in well-being among all classes, which has gradually brought typhus down almost to extinction (or apparently so for the present), has been attended with an increase of typhoid, an increase which has happily fallen within the last few years from its highest point.

The disappearance, during the last twenty years, of typhus and relapsing fevers from the observation of all but a few medical practitioners in England, Scotland and Ireland, is one of the most certain and most striking facts in our epidemiology. Most of the recent English cases have occurred in Lancashire, especially in Liverpool, and in Sunderland, Gateshead, Newcastle and other shipping places of the north. In the decennial period 1871-80 the death-rate from typhus, per 1000 living, was 0·58 in Liverpool and 0·33 in Sunderland, rates which were about the same as those from enteric fevers. The rates in 1881-83 were also high in the same group of towns. As to other industrial centres, including the coal-districts of Cumberland, Wales and Scotland, it is probable that a good deal of typhus passes under the name of “typhoid,” the change in medical fashion having outrun somewhat the real change in the relative prevalence of each fever[401]. In Scotland the disease is still heard of from time to time in Glasgow, Edinburgh, Leith, Dundee, Aberdeen, Inverness and Thurso. In London the recent immunity from it is remarkable, but intelligible. First, the populace is better housed: we have got rid of the window-tax, rebuilt the houses in regular streets opening upon wide thoroughfares, pulled down most of the back-to-back houses, dispersed the working population over square miles of suburbs easily accessible from the heart of the town by tramways and railways, perfected the sewerage and the water-supply. These great structural changes are so far an earnest that typhus cannot come back in the old way. Secondly, food has been for a long time cheap and wages good. During the remarkable lull in typhus from 1803 to 1816, Bateman pointed out that the unwholesome state of the dwellings of the working class remained the same as before, but that money was flowing freely among all classes (thanks to the special war-expenditure). Under free trade, the same abundance of the necessaries of life has been secured in another way. Typhus, it need hardly be said, is an indigenous or autochthonous infection; the conditions of its engendering are never very far off. In a small and remote island off the coast of Skye, which I happened to know in its pleasing aspects from having landed upon it during a summer vacation, typhus fever was reported by the newspapers a few months after to have broken out in the hamlet of twenty or thirty families, the winter storms having prevented the fishers from leaving their cottages or any stranger from approaching the island. In a sparsely populated parish of the east coast of Scotland, two cases of genuine typhus (one of them fatal), and two only, have occurred, to medical knowledge, within the last ten years, each in a very poor cottage in a different part of the parish and in a different season. So long as our cheap supplies of food, fuel and clothing are uninterrupted, there is small chance of typhus or relapsing fever. But the population of England being now twice as great as the home-grown corn can feed, a return of those fevers on the great scale is not out of the question in the event of the foreign food-supply being interfered with, or the necessaries of life becoming permanently dearer from any other cause.

The following Table of the fever-deaths in Scotland since the beginning of Registration does not distinguish enteric from typhus, relapsing and simple continued during the first ten years of the period; but it is probable, from all that is known non-statistically or by hospital figures only, as to the history of enteric fever in Scotland, that it made the smaller part of the generic total of fever-deaths so long as typhus and relapsing fevers were common.

_Scotland--Deaths from the Continued Fevers since the beginning of Registration._

Year

1855 2419 }
1856 2363 }
1857 3087 }
1858 2790 }
1859 2436 } Inclusive of typhus, relapsing, enteric
1860 2344 } and other continued fevers.
1861 2579 }
1862 3021 }
1863 3441 }
1864 4804[402]}

Simple Infantile Cerebro-Spinal
Typhus Enteric Relapsing continued Remittent

1865 3272 1048 62 839 164 --
1866 2172 1404 34 249 159 --
1867 1745 1378 40 105 119 --
1868 1561 1404 45 100 132 --
1869 2059 1335 29 121 157 --
1870 1460 1207 205 151 141 --
1871 1129 1234 411 108 124 --
1872 795 1223 115 103 118 --
1873 628 1495 31 192 117 --
1874 726 1455 27 104 80 --
1875 615 1625 17 98 85 --
1876 471 1448 18 65 88 --
1877 265 1427 5 164 -- --
1878 263 1477 2 147 -- --
1879 210 1013 5 133 -- --
1880 170 1338 4 155 -- --
1881 229 1004 0 115 -- --
1882 180 1204 2 90 -- --
1883 152 998 1 71 -- 7
1884 138 1050 2 63 -- 9
1885 111 889 1 58 -- 8
1886 80 755 2 62 -- 10
1887 126 835 7 65 -- 4
1888 102 665 6 58 -- 6
1889 69 795 1 45 -- 2
1890 77 777 -- 30 -- 3
1891 107 799 4 23 -- 6

Circumstances of Enteric Fever.

The circumstances of typhus and relapsing fevers need no general stating after what has been said of particular epidemics in England and Scotland, or remains to be said, for the most distinctive instances of all, in the chapter on fevers in Ireland. There has been so little typhus in the country at large since the disease began to be registered apart in the mortality returns, in 1869, that hardly anything can be inferred except the fact of its disappearance. It is significant, however, that Sunderland, one of the two great towns which have kept typhus longest and in largest measure (Liverpool being the other) is distinguished for the overcrowding of its dwelling-houses (7·24 persons to a house in the Census of 1881, 7·00 in the Census of 1891).

But the circumstances of enteric fever are not only not so obvious as those of typhus in the historical way; they are also more complex and disputable. One fact in the natural history of enteric fever has been made clear in the chronology, namely, its greater frequency after a severe drought. It was in the autumn of 1826, after the driest and hottest summer of the century, that cases of fever with ulceration of the bowel were first described and figured in London. It was in the autumn of 1846, after the next very dry and hot summer, that cases of the same fever again became unusually common in many parts of England and Scotland. The same sequence has been remarked on more recent occasions and in various countries. It is explained by taking into account some other facts in the natural history of enteric fever. In nearly all countries in our latitudes, autumn is its principal season, and autumn is the season when the level of the water in the soil, or in the wells, is lowest. Virchow states the law of enteric fever in the following simple and concrete way: “We [in Berlin] have a certain number of cases of typhoid at all times. The number increases when the sub-soil water falls, and decreases when it rises. Every year, at the time of the lowest level of the sub-soil water, we have a small epidemic.” A sharp rise above the mean level of the year, from the first week of September to the end of October, has been well shown for London from the admissions to the hospitals of the Metropolitan Asylums Board, 1875-1884. The curve has an equally sharp descent, passing below the mean line of the year in the second week of December[403]. There are indications that it is the partial filling of the pores of the sub-soil with water, after they have long been occupied with air only, that makes the virus of typhoid active, or, in other words, that the rains of late summer and autumn are the occasion of the seasonal increase of the infection.

Yet it is not the changes in the ground-water by themselves, just as it is not rainfall and temperature by themselves, that make enteric fever to prevail. The soil in which those vicissitudes of drought and saturation are potent for evil must be one that is befouled with animal organic matters, more especially with excremental matters. For that and other reasons (such as the geological formation), enteric fever shows, in its more steady or endemic prevalence from year to year or from decade to decade, certain marked preferences of locality. Since 1869, when the deaths from it began to be registered apart, it has been much more common, per head of the population, in the quick-growing manufacturing and mining towns than in any other parts of England and Wales, the districts with highest enteric death-rates being the mining region of the East Coast from the mouth of the Tees to somewhat north of the Tyne, the mining region of Glamorgan, certain manufacturing towns of Lancashire and the West Riding of Yorkshire, and some districts in the valley of the Trent in Staffordshire and Nottinghamshire. The following Table shows, by comparison with all England and Wales and with London, the excessive death-rates from enteric fever in the registration divisions which head the list:

_Highest mortalities from Enteric Fever in Registration Divisions of England and Wales_[404].

------------------------------------------------------------------
Decennium | Decennium
1871-80 | 1881-90
-------------------------------------------------------|----------
| Annual | Annual | |
|death-rate,|death-rate,|Enteric| Deaths,
|all causes,| Enteric, |Deaths | Enteric,
| per 1000 | per 1000 | in 10 | in 10
| living | living | years | years
-----------------------|-----------|-----------|-------|----------
England and Wales | 21·27 | 0·32 | 78421 | 53509
London | 22·37 | 0·24 | 8536 | 7497
-----------------------|-----------|-----------|-------|----------
Durham co. | 23·77 | 0·56 | 4525 | 2590
South Wales | 21·09 | 0·45 | 3715 | 2550
W. Riding, Yorks. | 23·24 | 0·45 | 9166 | 5170
N. Riding, Yorks. | 19·68 | 0·44 | 1259 | 896
Nottinghamshire | 21·23 | 0·43 | 1707 | 1263
Lancashire | 25·17 | 0·39 | 12388 | 9874

_Durham Mining Districts._

Stockton incl. part of | | | |
Middlesborough | | | |
(4¾ years) | 26·64 | 1·09 | 561 | --
| | | |
Stockton (5¼ years) | 22·49 | 0·62 | 208 | 258
| | | (5¼ |
| | | years)|
Guisborough, incl. part| | | |
of Middlesborough | | | |
(4¾ years) | 24·80 | 1·17 | 251 | --
| | | |
Guisborough | | | |
(5¼ years) | 20·45 | 0·38 | 71 | 106
| | | |
Middlesborough[405] | | | |
(5¼ years) | 19·93 | 0·63 | 272 | 460
| | | (5¼ |
| | | years)|
| | | |
Auckland | 24·52 | 0·71 | 541 | 318

_South Wales Mining Districts._

Pontypridd[406] | 23·16 | 0·71 | 515 | 541
Merthyr Tydvil | 24·23 | 0·62 | 639 | 249
Swansea | 22·38 | 0·63 | 505 | 387
Llanelly | 20·93 | 0·8 | 330 | 165

In the second decennium of the Table, 1881-90, the total deaths from enteric fever (the death-rates are still unpublished) are much below those of 1871-80. All the counties of England and Wales have shared in that notable decline, including Durham and Glamorgan. But these two great districts of the coal and iron mining are, by the latest returns, still keeping the lead; and it is probable that we shall find in them, or in particular towns within them, the conditions that have been most favourable to enteric fever in the earlier decennia of this century and are still favourable to it. First it is to be observed that one of the most noted of the old typhoid centres in Glamorgan, namely Merthyr Tydvil, has ceased to be in that class; its enormous rate of growth has been checked (to 18·9 per cent. from 1881 to 1891) and it has at the same time become a more uniform and better-ordered municipality.

On the other hand, on the same river Taff, and in the tributary valley of the Rhondda, there is an immense population of miners, among whom the enteric fever death-rate will probably be found to have been higher in 1881-90 than in any other registration district. The most populous part of the district is the town of Ystradyfodwg, which had 44,046 inhabitants in 1881 and 68,720 in 1891, an increase of over fifty per cent., the highest urban rate of increase in the country. On the mean of the last three years, 1891-93, its enteric fever death-rate has been ·62 per 1000. There are several populous towns or townships in the mining districts of the north-east which have in like manner kept their high rate of typhoid mortality--Auckland, Easington, Bellington (Morpeth) and Middlesborough. It is held by many that enteric fever has been most characteristically a product of the modern system of closet-pipes and sewers. It is, of course, the defects of the system that are, in this hypothesis, to blame, including its partial adoption, the transition-state from the older system, the tardy extension to new streets, as well as cheap and faulty construction. All those things, together with the inherent difficulty of connecting with a main sewerage the irregular squattings of a mining community, are probably to be found in highest degree in those districts of Durham and South Wales that are most subject to enteric fever. While enteric fever is in some places steady or endemic from year to year, in others its force is felt mostly in great and sudden explosions.

One such happened in the city and district of Bangor in the summer of
1882. The registration district had only 95 deaths from enteric fever
in the ten years 1871-80, but in the single year 1882 it had 87 deaths
registered under that name. Of 548 attacks (with 42 deaths) which were
known from 22 May to 12 September, 407 fell in August and the first
twelve days of September[407]. In the following year and throughout
the rest of the decennium the district had its usual low average of
enteric-fever deaths. One thing relevant to the explosion was probably
the excessive rainfall of June and July (9·5 inches, as compared with
4·8 inches about London).

Another explosion, probably unique in the history of enteric fever,
took place at Worthing, on the Sussex coast, in the summer of 1893.
The enteric death-rate of the town had been much below the average of
England and Wales from 1871 to 1880, the rate being 0·15 per 1000 and
the whole deaths in ten years 36. During the next ten years, 1881-90,
the whole enteric deaths were 43 in the entire registration district
(population in 1891, 32,394). In 1891 the typhoid deaths were two, in
1892 they were six. In 1893 a severe outbreak of typhoid took place
within the municipal borough (population 16,606): In the first quarter
of the year Worthing was one of the places mentioned for typhoid,
having had 5 deaths; in April there were no deaths, in May 25, in June
19, in July 61, in August 64, in September 11, and in the last quarter
of the year 8, making 193 deaths in the year. The highest weekly
number of cases notified was 253 in the second week of July. The
enormously wide dispersion of the poison, in a town little subject to
enteric fever, caused suspicion to fall on the water-supply, the more
reasonably that the district of West Worthing, which had a separate
water-supply, was said not to have suffered from the outbreak. A new
water-supply was at once undertaken. A relief fund of £7000 was raised
for the sufferers.

The towns of Middlesborough, Stockton and Darlington, in the lower
valley of the Tees, were together the scene of two remarkable
explosions of enteric fever, the first from 7 September to 18 October,
1890, the second from 28 December, 1890, to 7 February, 1891. The
phenomenal nature of these outbreaks in the autumn and winter of
1890-91 will appear from the following table of deaths by enteric
fever:

Darlington Stockton Middlesborough
Ten years 1881-90 104 258 460
-----------------------------------
1890 21 66 130
1891 17 59 93

In the first of the two explosions the three towns were almost equally
attacked per head of their populations; in the second explosion, in
mid-winter, Darlington had relatively only half as many cases as each
of the other two, which had about the same number of cases as in the
former six-weeks’ period. In both periods, of six weeks each, the
three towns had together 1334 cases of typhoid, while the country
districts near them had a mere sprinkling. A flooded state of the Tees
appeared to be a relevant antecedent to each of the explosions. The
Tees is a broad shallow river flowing rapidly, subject to frequent
inundations, tortuous in its lower course, forming at its mouth, where
Middlesborough stands, a wide estuary bordered by low flat grounds.
The rainfall at Middlesborough was 6·3 inches in August, of which 2·2
inches fell on the 12th of the month, the river being high in flood
thereafter. There were again high floods in November, chiefly caused
by the melting of snow in the upper basin (5 inches fell at Barnard
Castle in November, 3·1 inches at Middlesborough, while the December
fall was 1·2 inches at the former and 1·4 inches at the latter). To
apply correctly the ground-water doctrine of enteric fever to these
explosions, other particulars would have to be known, more especially
the extent of the previous dryness of the subsoil (the rainfall at
Middlesborough was 9·3 inches in the first half of 1890, 15·6 in the
second half, and below average for the whole year). But the flooded
state of the Tees valley in August and November must have changed
abruptly the state of the ground-ferments within the areas of the
respective towns and so afforded, according to the general law, the
conditions for an abrupt increase of enteric fever in these its
endemic or perennial soils[408].

While the more or less steady or endemic prevalence of typhoid fever is due to the formation and reproduction in the soil of an infective principle (probably of faecal origin) which affects more or less sporadically the individuals living thereon, after the manner of a miasma rising from the ground, there have been some hardly disputable instances of the infection being conveyed to many at once from a single source in the drinking water and by the medium of milk[409]. But such instances, suggestive though they be and easy of apprehension by the laity, must not be understood as giving the rule for the bulk of enteric fever. In like manner, the escape or reflux of excremental gases from pipes or sewers, or the leakage into basements or foundations from faulty plumber-work, are causes, real no doubt, but of limited application, which do not conflict with, as they do not supersede, the more comprehensive and cognate explanation of enteric fever as an infection having its habitat in the soil and an incidence upon individuals after the manner of other miasmatic infections. Sex has little or nothing to do with the incidence of the infective virus. As to age, enteric fever rarely befalls infants, and, in the general belief of practitioners, is a less frequent cause of death among children than among adolescents and adults.

In the following Table from the Registrar-General’s Decennial Review,
1871-80, enteric fever is not separated from other continued fevers.
It is probable that a considerable ratio of the deaths from 0 to 5
years are due to febrile disorders other than enteric.

_Annual Mortality per million living at all ages and at eleven groups
of ages, males and females, from fever (including Typhus, Enteric
Fever and Different Forms of Continued Fever) 1871-80._

All
ages 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75+

Both sexes 484 651 518 439 543 509 411 379 402 458 553 498
Males 494 644 483 390 513 579 436 395 437 503 629 593
Females 477 658 550 487 573 445 387 362 369 418 488 425

The cases notified under the Act in 1891 and 1892 have been found to average five or six for every death registered in the corresponding districts, the rate of fatality ranging widely. It is matter of familiar knowledge that many of the attacks and fatalities occur among the richer classes. New comers to an endemic seat of the disease are most apt to take it (this has been elaborately shown for Munich, and holds good for the British troops in India). There are undoubtedly constitutional proclivities to it among individuals, which may run strongly in families. As in other miasmatic infective diseases, such as yellow fever, Asiatic cholera, and (formerly) plague, there seem to be occasions in the varying states of body and mind, as well as in the external circumstances, when the infection of enteric fever is specially apt to find a lodgement and to become effective. The old plague-books gave lists of the things that were apt to invite venom or to stir venom (see former volume pp. 212, 674); and it is probable that some of these hold good also for the incidence of enteric fever.