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