Chapter I · (continued 6)

Hospital Cases of Typhus, 1849-71.

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

Year Typhus Simple or 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.

Year Typhus Simple or 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:

Deaths in London from both fevers Admissions to London Fever Hospital

Year 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 } } } } } } Inclusive of typhus, relapsing, enteric and other continued fevers.

1856 2363

1857 3087

1858 2790

1859 2436

1860 2344

1861 2579

1862 3021

1863 3441

1864 4804[402]

Typhus Enteric Relapsing Simple continued Infantile Remittent Cerebro-Spinal

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 1871-80 Decennium 1881-90

Annual death-rate, all causes, per 1000 living Annual death-rate, Enteric, per 1000 living Enteric Deaths in 10 years Deaths, Enteric in 10 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 (5¼ years) 258

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 (5¼ years) 460

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.