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.

CHAPTER II.

FEVER AND DYSENTERY IN IRELAND.

The history of the public health in Ireland has been so remarkable that it may be useful to take a continuous view of it in a chapter apart, so far as concerns flux, or dysentery, and typhus with relapsing fever.

Ireland is a country which would have given Hume, had he thought of it, the best of all his illustrations of the difficult problem handled in the essay “Of National Characters”—how far the habits, customs, temperaments and, he might have added, morbid infections have been determined by climate, and how far by laws and government, by revolutions in public affairs, or by the situation of the nation with regard to its neighbours. Not only is there something special and peculiar in the actual epidemiology of Ireland, but its political and social history has been apt to borrow the phrases of medicine in a figure. “First the physicians are to take care,” says Burke, “that they do nothing to irritate this epidemical distemper. It is a foolish thing to have the better of the patient in a dispute. The complaint, or its cause, ought to be removed, and wise and lenient arts ought to precede the measures of vigour[410].” And this singular use of the imagery of disease in Irish history might be illustrated from many other passages of the same orator and essayist, just as it may be seen any day in the columns of newspapers in our own time. Giraldus Cambrensis began it, within a few years of the first English conquest of Irish territory by Henry II. Writing of that singular effect upon the English settlers by contact with the native Irish, whereby they became, in the words of another medieval author, ipsis Hibernis hiberniores, he resorts to the medical figure of “contagion” as the best way to account for it. So again, to overleap six centuries, Bishop Berkeley in his query “whether idleness be the mother or daughter of spleen[411],” is trying upon the Irish both Hume’s problem of national character and the use of the medical figure. And, to take a modern instance, Lord Beaconsfield used the same figure of the old humoral pathology, and gave his adhesion to a theory of national characters adverse to the sense of Hume, when he ascribed the habits and manners of the Irish, and the course of their national history, to their propinquity to a “melancholy” ocean.

As far back as we can go in the history, two diseases are conspicuous—the flux or “the country disease,” and the sharp fever or “Irish ague.” When Henry II. invaded Ireland in 1172, his army suffered from flux, which the contemporary chronicler, Radulphus de Diceto, dean of St Paul’s, set down to the unwonted eating of fresh meat (recentium esus carnium), the drinking of water, and the want of bread[412]. Less than a generation after, Giraldus of Wales wrote his “Topography of Ireland,” wherein he remarks that hardly any stranger, on his first coming to the country, escapes the flux by reason of the juicy food (ob humida nutrimenta)[413]. At that time Ireland was almost wholly a pastoral country, and a pastoral country it has remained to a far greater extent than England or Scotland. It is to this comparative want of tillage, an almost absolute want when Giraldus was there, that we shall probably have to look in the last resort for an explanation of the two national maladies that here concern us—the “country disease” and the “Irish ague.” The same dietetic reason that the dean of St Paul’s gave in 1172 for the prevalence of flux in the army of Henry II., the want of bread and the eating of fresh meat, can be assigned for the country disease long after, and, in some periods, on the explicit testimony of observers. As to the Irish ague, or typhus fever, Giraldus mentions it in the medieval period; and Higden, copying him exactly, says: “The inhabitants of Ireland are vexed by no kind of fever except the acute, and that seldom”—the word acuta being the original of “the ague,” or, as in another translation of the passage, “the sharp axes[414].” In this pastoral country, according to Giraldus, there was little sickness and little need of physicians; but there is hardly an instance of military operations by the English unattended with sickness among the troops, and famine with sickness among the native Irish.

The generalities of Fynes Moryson, a traveller of the time of James I., who included Ireland among the many countries that he visited and described, throw light upon the dietetic peculiarities of the Irish. Having little agriculture, and at that time no general cultivation of the potato (although they adopted it much sooner than the English and Scots), they lived, says Moryson, mostly on milk (as Giraldus Cambrensis also records in the twelfth century), and upon the flesh of unfed calves, which they cooked and ate in a barbarous fashion. “The country disease” is also noted. The experience in Ireland from time immemorial, that a bellyful was a windfall, must have been the origin of a habit observed by Moryson:

“I have known some of these Irish footemen serving in England to lay meate aside for many meales to devoure it all at one time.” And again: “The wilde Irish in time of greatest peace impute covetousnesse and base birth to him that hath any corne after Christmas, as if it were a point of nobility to consume all within these festivall dayes.” The Irish slovenliness or filthiness in their food, raiment and lodging was apt, he says, “to infect” the English who came to reside in their country[415].

About a generation after we come to the earliest medical account of the sicknesses of Ireland, by Gerard Boate, compiled during the Cromwellian occupation[416]. The following occurs under the head of The Looseness:

The English have given it the name of the Country Disease. The subjects of it are often troubled a great while, but take no great harm. It is easily cured by good medicines: “But they that let the looseness take its course do commonly after some days get the bleeding with it; ... and last it useth to turn to the bloody flux, the which in some persons having lasted a great while, leaveth them of itself; but in far the greatest number is very dangerous, and killeth the most part of the sick, except they be carefully assisted with good remedies.”

The other reigning disease is the “Irish Ague,” a continued fever of the nature of typhus:

“As Ireland is subject to most diseases in common with other countries, so there are some whereunto it is peculiarly obnoxious, being at all times so rife there that they may justly be reputed for Ireland endemii morbi, or reigning diseases, as indeed they are generally reputed for such. Of this number is a certain sort of malignant feavers, vulgarly in Ireland called Irish agues, because that at all times they are so common in Ireland, as well among the inhabitants and the natives, as among those who are newly come thither from other countries. This feaver, commonly accompanied with a great pain in the head and in all the bones, great weakness, drought, loss of all manner of appetite, and want of sleep, and for the most part idleness or raving, and restlessness or tossings, but no very great nor constant heat, is hard to be cured.” If blood-letting be avoided and cordial remedies given, “very few persons do lose their lives, except when some extraordinary and pestilent malignity cometh to it, as it befalleth in some years.” Those who recover “are forced to keep their beds a long time in extreme weakness, being a great while before they can recover their perfect health and strength.”

The occasion of Boate’s writing was the subjugation of Ireland by Cromwell, in the course of which we hear from time to time of sickness. The greatest of the calamities was the utter destruction of the prosperity of Galway by the frightful plague of 1649-50, and by the suppression of the Catholics, who had brought the port of Connaught to be a place of foreign commerce[417].

Cromwell’s troops in 1649 incurred dysentery through the hardships of campaigning. On 17 September, 1649, the Lord General writes from Dublin to Mr Speaker Lenthall after the storming of Tredah or Drogheda: “We keep the field much; our tents sheltering us from the wet and cold. But yet the country-sickness overtakes many: and therefore we desire recruits, and some fresh regiments of foot, may be sent us.” And on 25 October, “Colonel Horton is dead of the country-disease[418].”

Another general reference to the “country disease” of Ireland, by Borlase, is very nearly the same as Boate’s. It is introduced early in the history, on the occasion of the death in 1591 of Walter, Earl of Essex, earl marshal of Ireland:

“The dysentery, or flux, so fatal to this worthy person, is commonly termed the country disease; and well it may, for it reigns nowhere so epidemically as in Ireland; tainting strangers as well as natives. But whether it proceeds from the peculiar disposition of the air, errour in diet, the laxity and waterishness of the meat, or some occult cause, no venomous creature living there to suck that which may be thought (in other countries) well distributed amongst reptilious animals, I shall not determine, though each of these circumstances may well conduce to its strength and vigour. Certain it is that regular diet preserves most from the violence, and many from the infection of this disease; yet as that which is thought very soveraign—I must say that the stronger cordial liquors (viz. brandy, usquebeh, treacle and Mithridate waters) are very proper, or the electuaries themselves, and the like[419].”

From the Restoration to the Revolution little is known of epidemics in Ireland. It is probable that Dublin and the other considerable towns fared much the same as English towns. A Dublin physician writing to Robert Boyle on 27 February, 1682, speaks of a petechial fever, marked by leaping of the tendons, which had been fatal to very many in that city for these twelve or fourteen months[420]. With the Revolution the troubles of the country begin again, and enter on their peculiarly modern phase. For our history, two characteristic incidents come at the very beginning of the new period of disorder among the Irish—the sicknesses of the siege of Londonderry and the unparalleled havoc of disease among the troops of Schomberg in the camp of Dundalk. In both, the old “country disease,” which had affected Cromwell’s troops, was the primary malady, occurring, of course, in circumstances special enough to have bred it anywhere; in both, the dysentery was attended or followed by typhus fever, the old “Irish ague;” and although the epidemics of Londonderry and Dundalk in 1689 are properly examples of war sickness, yet the circumstances of each may help to realize the connexion between dysentery and typhus in the ordinary history of the Irish.