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