Durham Mining Districts.

Stockton incl. part of
Middlesborough
(4¾ years)		26·641·09561—
Stockton (5¼ years)22·490·62208
(5¼ years)		258
Guisborough, incl. part
of Middlesborough
(4¾ years)		24·801·17251—
Guisborough (5¼ years)20·450·3871106
Middlesborough[405]
(5¼ years)		19·930·63272
(5¼ years)		460
Auckland24·520·71541318
South Wales Mining Districts.
Pontypridd[406]23·160·71515541
Merthyr Tydvil24·230·62639249
Swansea22·380·63505387
Llanelly20·930·8330165

In the second decennium of the Table, 1881-90, the total deaths from enteric fever (the death-rates are still unpublished) are much below those of 1871-80.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 1881-90104 258 460
189021 66 130
189117 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.