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.