Enteric fever at Norwich

ENTERIC

FEVER

NORWICH,

AT

379

TABLe.H.~,howingthe Percentage of Married.Women. Occupied, and the Percentage of Infants. returned as Infants of Occupied. Married Women, in 1881 and xS9U m WhRworth, Wardleworth, and Bletchmworth Sub-l:~egistratiou Districts of Rochdale. Number of Married Women. fx88t . . . . . . . . . . . . '9t .........

3,704

~"188z . . . . . . . . . . . .

3,532

.........

3,441

Bletchinworth f188I -[ '9~ . . . . . . . .. .. .. .. .. . . . .

1,390

Whitworth ...... [ Wadleworth

""l. '91

Percentage returned as Occupied.

Number of Infants.

3,297

1,44~

After marriage the patients at our hospitals are generally described merely as wives; the occupation of the husband being given, and the occupation of the wife before marriage is of course not noted. But much of the injury done to young girls by working long hours under unhealthy conditions only shows itself in an acute form after marriage. There is also another reason why no trustworthy statistics of the effect of industrial employment on women's health are forthcoming: a large proportion of the young women and girls employed inour large towns as domestic servants, shop assistants, and (to a less extent) dressmakers come from the country. I f attacked by any severe illness they are always removed from their employers' premises, and, if possible, sent back to their friends in the country. T h e death certificate in such cases would probably contain no reference to occupation, as after a long illness the girl would be regarded as having been of no occupation. Out of 476 female shop assistants in representative West End streets in 189I , 28 per cent. were born in London. 18 per cent. were born in Kent, Sussex, Surrey, Hampshire, or Berkshire. IO per cent. were born ~n Hertfordshire, Middlesex, Buckinghamshire, Oxfordshire, Huntingdonshire, Bedfordshire, or Cambridgeshire. Io per cent. were born in Essex, Suffolk, or Norfolk. 15 per cent. were born in Wiltshire,'Dorsetshire, Somersetshire, Gloucestershirej Devonshire, or Cornwall. 4 per cent. were born in Herefordsbire, Shropshire, Staffordshire, Worcestershire, or Warwickshire. 3 per cent. were born in Lincolnshire, Notiinghamshirej or Leicestershire. 4 per cent. were born in Lancashire, Cheshire, or ¥orkshire~ 5 per cent. were born in Wales or Monmouthshire. 3 per cent. were born in the Northern Counties, Scotlandj or Ireland. I see no way of reforming our industrial statistics of health except by the efforts of private persons, and few medical men with large numbers of working-class patients can spare time for such investigations. Patient follows patient so rapidly

Percentage returned as Children of Occupied Manied Women.

33'5

544

a8"2

408

*'7"6 x5"7

26"7

33"5

5]5 437

28 "3 20 "4

26 "7

206

x6"5 8"2:

23 '4

146

that there is barely time to ascertain the disease that requires cure, and none to go into questions of its origin. The establishment of anthropometrical laboratories in every large industrial centre could alone enable us to arrive at the knowledge we ought to have of the effect of the half-time system on the physique of children, a n d - - e v e n more important, p e r h a p s - - t h e effect of full time on the-physique of girls between I 4 and z8.

ENTERIC

FEVER

AT

NORWICH. #

As the relative prevalence o f this disease is a commonly accepted criterion of the sanitary condition of a district, its associations and surroundings become of special interest, the more particularly so as enteric fever is rather endemic than epidemic in Norwich. The geological construction of the soil underlying the city is simple in character. The higher levels are made up of glacial beds, through which the valleys have been excavated, exposing at their margins the crag formation and chalk, while gravel and alluvial deposits occupy the lower ground. T h e chalk, which at Norwich is more than I,ooo feet thick, and underlies the whole of the city, comes to the surface in the Market Place, and in other places at a similar level; but it may be reached at no great depth in all parts of the municipal area. T h e order of the succession of the glacial and crag beds is shown in excavations on the sides of the high ground surmounted by Mousehold Heath, between which heath and the city proper, winds the valley of the Wensum. Except for some layers of peat in the valley, and a bed of brick-earth over part of the higher ground ~near the Victoria Station), the soil of the city is of In part from a paper by H. Cooper Pattin, M.A., M.B., " Enteric Fever at Norwich--a Triennium of Typhoid," read before the Epidemiological Society on May 2oth last, and in part fIom Dr. Cooper Pattin's Annual Report for I897. 2E2

380

ENTERIC

FEVER

a porous character, a n d m u c h percolation o f fluid takes place through the gravels, etc., into the chalk. T h e general trend of the drainage of the greater portion of the inhabited area of the city is toward the W e n s u m . T h e water supply of the city is derived in part from the W e n s u m and in part from private wells, s o m e of the latter being described as excellent, others as doubtful. T h e subject of the gross pollution of the W e n s u m has been considered by the councils of the county, city and districts more specially c o n c e r n e d therewith. T h e existing sewers are very faulty and new sewers are in process of construction. U n t i l recently, the street gullies were untrapped, but now gully pots are being extensively put in. Ventilation shafts are replacing the old road gratings. Notification was adopted in I879, and the record o f cases since then is given in the following table : PREVALENCE A N D

iV[ORTALITY iN P A S T Y E A R S .

Year.

Notifications of]

No. of

188o 1881 1882 1883 1884

I8O 5° 47 34

37 15 8 II

/ / ] /

121 584 262 136

{O

I885 1886 I887

1888 1889 189o I89I 1892 1893 1894 1895 1896 1897

I7~ 166 176 ~63 lO6 314 x5o 226 196 234

19

)2

39

[ Mortality Rate.

[ / ] L

2 o ' 5 per cent. 30"0 p,

I7"4 32"3 24"8 15 "6 14"5 14"7

,, ,, ,, ,,

,, ,,

20

II'I I3'2 17"6 12"8 I7'9 11 4 I4'6 IO"6 I0"2

,, ~., ,, ~ ,, .~ j, p~ ~,

33

I4"o

,,

22

3i r9 36 22

24

In 1887 the notifications averaged one to every 682 inhabitants, and in I897, one to every 479. I t will be noticed that whereas the death-rate in 188o from this disease averaged 2o" 5 per cent. of the cases notified, or, roughly, one case in every five, the death-rate last year was one case in every seven. It does not necessarily follow that these figures represent the true state of the facts. T h a t there has been on the whole a diminution in the case mortality cannot be doubted ; but it m u s t be r e m e m b e r e d that most probably a n u m b e r of the m i l d e r cases o f t h e disease were not recognised and notified in I88O. Increasing skill in diagnosing t h e disease in its lighter form has, in my judgment, led to a more accurate correspondence between the n u m b e r of notifications sent in and the actual a m o u n t of the disease, although I still think that a n u m b e r of cases of enteric fever, of what is known as the " a m b u l a t o r y " type, escape notification and n e v e r receive medical treatment ;

AT

NORWICH.

so that in Norwich, as elsewhere, the notifications furnish a reliable guide to the relative prevalence of the disease, but must not be r e g a r d e d as accurately representing the full amount. T u r n i n g now to the 234 cases notified in 1897 , and comparing t h e m with 1896 and 1895 , we find : - (a) Sex : T h a t 49"5 per cent. of the cases r e p o r t e d in 1897 occurred in males, and 50"5 per cent. in females, whereas in 1896 , 5 i ' 5 per cent. occurred in males, a n d 48" 5 per cent. in females ; and in 1895 only 44"2 per cent. were males and 55"8 females. W h y these changes have occurred I do not k n o w ; the females are c o m m o n l y m o r e h o m e keeping in their habits than the m a l e s ; on the o t h e r hand, the latter expose themselves to m o r e extended m e a n s o f infection. Average, three years (I895-97) : Males, 48'4 per cent. ; Females, 52"6 per cent. (a) Age : Three In 1897. 1896 . 1895. Years' Average. 12"5 per cent. of the patients were under 5 years of age ...... 9"2 7"5 9"75 18'75 per cent. of the patients were between 5 and IO years of age ... 15"3 zz'5 18"85 17"o per cent. of the patients were between IO and I5 years of age 2 5 " 0 1 8 " 5 23"5 16"75 per cent. of the patients were between 15 and zo years of age 17'3 17"75 I7"25 I2"O per cent. of the patients were between 2o and 25 years of age 9"2 IO'O lO'4 12'25 per cent. of the patients were between 25 and 35 years cff age 15' 3 12"75 13"4 7"25 per cent. of the patients were between 35 and 45 years of age 6'2 5"75 6"4 4"5 per cent. of the patients were over 45 years of age . . . . . . 2"5 5"25 4"0 T h e rise which o c c u r r e d between the ages of twenty-five and thirty-five in I896 was not maintained. It will be n o t i c e d that no less than 48'0 per cent. of the cases o c c u r r e d in children under fifteen years of a g e - - w h a t may be called juvenile typhoid being a m a r k e d characteristic of the enteric fever which prevails in Norwich. In 1896 , 48'5 per cent. m o r e eases in persons over forty five years o f age were notified, in fact nearly double the n u m b e r which reached us in I896. T h e r e were more cases u n d e r five t h a n in either of the preceding years. T h e average n u m b e r of cases under fifteen years of age in the three years was 48'6. (c) Crowding : AVERAGE N U M B E R

OF OCCUPANTS.

7"5 p e r cent. of the affected d w e l l i n g s h a d

only I bedroom . . . . . . . . . . . . 37'o per cent. of the affected dwellings had only 2 bedrooms . . . . 42"5 per cent. of the affected dweliings h£t'ci only 3 bedrooms . . . . . . . . . . 13"o per cent. of the affected dwellings had only 4 bedrooms or more ......

3~ persons. 2½ persons. ~ persons. 1 person.

ENTERIC

FEVER

AVERAGE OF THREE YEARS~AVERAGE NUMBER OF OCCUPANTS. 5"6 per cent. of the affected dwellings bad

only I bedroom ... 35"9 per cent. of the affectect'dwel'l~gshad only 2 bedrooms . . . . . . 46"5 per cent. of the affected'dweliings had only 3 bedrooms . . . . . . . II'8 per cent. of the affectecl"dwel'l'ingshad only 4 bedrooms or more ......

3"t6 persons.

2.5 persons. 2"2S persons. I person.

In x 8 9 6 the corresponding percentages were t bedroom, 4'4 per cent. ; 2 bedrooms, 36"7 per cent. ; 3 bedrooms, 49"4 per cent. ; and 4 or more bedrooms, 9"5 per cent. The relative crowding was 3, 2½, 2t, and i person per room. I n I895 these percentages were ~ bedroom, 5"° per cent. ; z bedrooms, 34'0 per cent. ; 3 bedrooms, 48"0 per cent. ; and 4 or more bedrooms, x 3 per cent. T h e relative crowding iri i895 was 3, z~, z ~ , and I, so that the disease in x897 invaded more of the worst and of the best houses than in 1896 , and more of the worst and fewer of the best than in ~895. I n estimating the influence of "man-crowding," I have only concerned myself about the number of sleeping rooms, the rooms in which crowding becomes important. T h e census returns are only helpful here in respect of tenements consisting of one room, which room must, of necessity, be used for bed and living room. At the ~89 x census there were 2"~ per cent. of the dwellings which consisted of one room o n l y ; and when it is remembered that a large proportion o f these are occupied by one old man or woman living alone, the incidence of the disease in one bed-roomed houses is probably much heavier than the figures represent. (d) Water:Supply : PERCENTAGES OF AFFECTED DWELLINGS SUPPLIED WITH COMPANY'S WATER.

I897--87'5 ; I896---85"5; i895---8i'o. Average for three years--84"6. PERCENTAGES SUPPLIED FROM PRIVATE WELLS. I897mI2"5 ; I896--I4"4 ; I895--I8"o. Average for three years--15"4.

T h e proportions in which houses are supplied with " p i p e " or with well water are quietly but continuously altering. Each year sees an increase in the number of houses supplied by the company, and a decrease in the number of those drawing water from wells. At the present time about 89 per cent. of the houses are supplied by the company with water, so that if the propagation of enteric fever is to b e attributed to water supplies, we have to impeach the company's supply as well as the water from wells. Thirty-seven wells were closed during the year, the water drawn from them being shown by chemical analysis alone to be unfit for drinking purposes. We have, thanks to a resolution passed by the Sanitary Committee, been enabled to submit the company's water to the much more rigid test of bacteriological investigat i o n , in a d d i t i o n to chemical analysis, with

AT NORWICH.

38t

satisfactory results. I do not m y s e l f believe that any serious portion of the prevalence of enteric fever was occasioned in 1897 by the consumption of contaminated water ; else we ought to have had a heaver incidence of the disease among the drinkers of well waters, and also among the wellto-do drinkers of the company's waters. That the company expends great care upon the filtration and storage of the water it supplies to the citizens, I feel it my plain duty to bear witness ; and s h o r t of the demonstration by bacteriological experts of the specific baciUus of enteric fever being distributed with the fluid, I see no sufficient reason for dissenting from the opinion expressed by the official analysts that it is " a perfectly safe w a t e r for dietetic use." (e) Milk supply : In I897. I896. t895. z'o per cent. of the patients drank no milk 8"0 IO'O 29"0 ,, ,, ,, it in the raw uncooked condition 24"0 25"3 68'o per cent. of the patients drani~ it oniy when first boiled or cooked in puddings or in hot tea, etc. . . . . . . 67"5 65'0 x'o per cent. of the patients used condensed milk . . . . . . . . . . . . I'O o'o On the average for the three years 6"6 per cent. of the patients d r a n k no milk, 26'o per cent. drank it in the raw uncooked condition, 66"8 per cent. drank it only when first boiled or cooked in puddings or in hot tea, etc., and o'6 per cent. used condensed milk. As in i896, I think that milk propagated little enteric fever among us ; its influence anyway must have been limited, for practically it could be only a source of infection in 3 ° per cent. of the cases among the drinkers of the uncooked article. At the same time I am bound to say that, but for the fairly general cooking of the milk consumed among us, we are practically at the mercy of the surrounding districts, so large a portion of our supply comes from outside the City ; and unfortunately the want of a county medical officer of health is felt in more than the arrangement of concerted action in t h e matter of milk supply between the city and county sanitary authorities. (r) Shell-fish : So far as I could learn, 76"o per cent. of t h e patients ate no shell-fish, either in the cooked or uncooked conditions, within three weeks of the outset of their ailment. I n I896 the corresponding percentage was 88'o, so that this possible source of infection could not affect more than one-fourth of the cases last year, even supposing that the whole of these ate their shell-fish in an uncooked condition. Three year average : 82"6 per cent. (g) Disposal of excrement : - 59"0 per cent. of the affected dwellings used "bins." 33"o ,, ,, ,, pail closets. 8"o

p,

__

.

water-closets. ..

382

ENTERIC

FEVER

In 1896 the proportion were 58'0 per cent., 32"0 per cent., and 12"o per cent., and in I895 64'0 per cent., 24"o per cent., and 12"o per cent. respectively. T h e relative increase in 1897 took place in the dwellings supplied with " b i n s " a n d pail closets. Three year average : " B i n s , " 6o" 3 per cent. ; pail closets, 29"3 per cent. ; and water-closets, lO'4 per cent. T h e number of houses supplied with waterclosets amounts t o a little more than one-fourth of the whole ; rather more than another fourth have pail closets, and the remainder "bins." Regarding the pail closets as small movable " bins" (which indeed they are), it will be seen that 92"0 per cent. (three year average : 89"6 per cent.) of the cases occurred in dwellings which retained the excrement of the occupants about them. (Jz) H o u s e h o l d Drainage : At 44'o per cent. only of the affected houses the inspectors reported the drainage as " g o o d . " I n ~896 the corresponding percentage was 4I"o per cent., and in 1895 , 39"o per cent. The average for the three years was 41" 3 per cent. That means in the others that some defect in the drainage, such as no sink (which means that all slop and other waste water would be pitched about the yard), sink waste-pipe not disconnected, or loose and defective " t r a p s , " etc. (i) Character of Yard : In I897. o'5 per cent. of the affected dwellings had no yard . . . . . . . . . . . . 3o'o per cent. of the dwellings haci paved yards . . . . . . 3I'5 per cent. of ih'e dwel'lings'i;ad nnpaved yards . . . . . . . . . 7"75 pet cent. of the dwellings had partly paved yards . . . . 30"5 per cent. ofthe'~twellingshaft cobble? ~ards ...............

I896. I "3 x9"o 31"o

1895. 2"0 33"0 35"o

7"75 9 .0 30"5 eI'O

Taking the three years, it appears that there was no yard in r'25 per cent. ; paved yards, 27.25 per cent. ; unpaved yards, 32"5 per cent. ; partly paved yards, 8"16 per cent.; and cobbled yards, 27" 3 per cent. I n other words, 7o per cent. of the dwellings had yards more or less liable to have the subsoil soddened with moisture and impurities. I have repeatedly drawn attention to the importance of having the soil which adjoins a dwelling covered with some material impervious to fluids, else it cannot be kept dry. A large number of the poorer dwellings in this city have no properly constructed " damp c o u r s e " in the walls, and, in addition, have not had a thick layer of concrete laid under the bottom floors ; in such cases moistening of the subsoil must lead to dampness in the dwelling, to say nothing of the deleterious ground air which will be forced upwards by the rising of the groundwater from time to time, and always more O~ less sucked into the dwelling owing to its atmosphere being warmer.

AT NORWICH. ( j ) Food Store : In 4"5 per cent. of the affected dwellings food was stored in a receptacle situated inside the living room, but having direct communication with the external air ; in 5"4 per cent. food was stored in a similarly ventilated receptacle elsewhere; 7"2 per cent. of the dwellings had the household food stored in an unventilated receptacle (namely, having communication with the external air) in some part of the house other than the living room ; and in no less than 82" 9 per cent. of the dwellings the food was stored in some unventilated receptacle in the actual living room. In ~896 the focd was similarly stored in 85" 4 per cent., and I895 in 86"0 per cent. of the affected dwellings. I t is worthy of notice that in 82" 9 (average for three years, 84"75) per cent. of the affected dwellings the food was stored in the giving room, and therefore in an atmosphere more or less stale and impure. Without assmning a direct connection between such food and a disease like enteric fever, it will be obvious that articles of food such as milk, butter, bread, etc., kept in such surroundings might easily become contaminated with impurities. (/?) Nearness to Sewer Gratings and Gullies : In I897. 1896. 1895. 17'o per cent. of the affected dwellings were within 20 ft. . . . . . . . . . I3"o I9"O 2o'o per cent. of the affected dwellings were within 4°ft . . . . . . . . . . 28"0 20"0 Three Year Average: 16" 3 per cent. within 20 ft., 22"6 per cent. within 40 ft. T h e remainder were over 4o ft. These measurements were taken because a stench from a grating or gulley had been so constantly charged by people near with occasioning enteric fever. My own belief is that pollution of the neighbouring air with sewer gas lowers the resisting powers of the body, and thus causes those exposed to so deleterious an influence to fall more easily a victim of disease. I am of opinion that the emanations from collections of excrement in " b i n s " and pail closets, and from heaps of decaying refuse, act in the like manner as powerful predisposers of disease. (/) Occupation of the Householders (in 1897) : - 179 dwellings were affected; 39 of these were occupied by ordinary labourers, 3 ° by shoemakers, 8 by persons following no definite occupation, classifying themselves as gentlefolk; 7 (each) by carmen and carpenters, 6 by starchworkers, 5 by shopmen, 4 (each) by mustard-workers and painters, 3 by brewery-men, wood-choppers, bricklayers, sewerage labourers, tinmen and printers, 2 (each) by milliners, gardeners, publicans, builders, fish-hawkers, stone-dressers, and horsehair weavers ; x (each) by a corporation labourer, a tobacconist, an ironworker, a hairdresser, a coffee-shop keeper, a shoe-factory manager, an accountant, a photographer, a cab proprietor, a coal porter, a hawker, a sawyer, an engineofitter, a ticket collector, a fish-

WATER.BORNE ENTERIC

FEVER AT CAMBORNE, CORNWALL.

monger, a shopkeeper, a drover, a bailiff, a railway clerk, a platelayer, a tailorPs purser, a domestic servant, a tailor, claarwoman, a paper-bag maker, a yeast merchant, a coal-heaver, a railway labourer, a railway guard, a waiter, a clerk, an engineer, a scavenger, a parlor, a plumber, a traveller, a basket maker, and a police constable. (m) Secondary Cases : ~ In thirty-one dwellings more than one member of the household contracted the disease; in fact, in these dwellings no less than forty-six cases occurred. In addition to these, nine cases were notified in public institutions: five in the workhouse, and four in the barracks. Taking all the facts brought to my notice in these detailed investigations during the past three years into consideration, the following summary represents the conclusions I have at present arrivedlat : - (~) That enteric fever (as shown by the number of notifications) has been prevalent in Norwich for the last seventeen years ; (2) That while there has been on the whole a seasonal increase of the disease in the autumn months, the disease has persisted throughout the year; (3) That what may be described as the endemicity of the disease in the city, appears to be associated with the methods of disposing of excrement followed, and with defects in the sewerage and drainage ; (4) That while specifically polluted water and milk may be occasional causes, there is no sufficient evidence that they constitute the main persisting causes ; (5) That bedroom crowding exerts a predisposing influence, probably by lowering the standard of healthiness in those subjected to such undesirable household conditions; (6) That emanations from sewer gratings, untrapped gullies, and more particularly collections of festering excrement exert a predisposing influence

in those exposed to them ; (7) That the existence of some thousands of fixed and movable " b i n s " is unquestionably a source of continuous pollution alike to the soil and the air in the neighbourhood of the dwellings, and affords favourable conditions for fostering a filthdisease like enteric fever; and that, in scavenging, portions of excrement are liable to fall on to and get trodden into imperfectly paved yards, alleyways, and streets ; and (8) That the high proportion of the chlorides and nitrates to be found in the soil of the city bears testimony to organicpollulion in the,as,, and

furnishes a favouring nidus for promoting the existence of the specific micro-organism of entericfever. RETURN CAs~.s.--The Metropolitan Asylums Board are about to appoint for a term of six months a medical expert to investigate all alleged " return cases" at the managers' hospitals.

383

WATER-BORNE ENTERIC FEVER AT CAMBORNE, CORNWALL. (Dr. BRUCE Low's Report to Local Government Board.) THE town of Camborne , not far from Truro, in the centre of the Cornish mining district, includes an area of 7,ooo acres and a population of x4,7oo. I n December, J 897, 85 cases of enteric fever occurred, followed by 37 in January, i898, and during the samo months 33 persons were attacked in part of the adjoining parish of Illogan and io in the neighbouring small village of Praze. The local Health Officers (Drs. Thomas and Permewan) ascribed the outbreak to the public water supply which is common to the three places invaded by the fever, but popular opinion asserted that the filthy conditions of refuse disposal and neglected scavenging, and the consequent emanation " o f a deadly gas called sulphuretted hydrogen " were the cause of all the trouble. As three sanitary districts were involved, Dr. Bruce Low was directed to investigate the outbreak, and his Report to the Local Government Board is an interesting contribution to the literature of water-borne typhoid and the peculiar characteristics of water companies' officials. Havingeliminated milkas a causeofthe epidemic and pointed out that the season had passed when outbreaks of enteric fever due to soil pollution chiefly occur, Dr. Low remarks that out of the total of x65 cases reported there were only two in which the illness was not due directly or indirectly to the water supplied by the Camborne Company, which water is not filtered. This company possess two gathering grounds, Cargenwyn and Boswyn. On the Cargenwyn watershed are 19 houses with 72 inhabitants, and the water is collected in three reservoirs, the overflow from the two higher passing to the lowest in an open brook or so-called "bye-wash." Of t h e , 9 houses mentioned, ~3 are without privies (5 of the latter being within xoo yards of the "bye-wash"), and their inhabitants have to defrecate on the fields, which are also top-dressed with human and animal manure. On the Boswyn catchment area the water from certain springs is piped to a service tank which is also fed by a brook, the latter being, in wet weather, subject to surface pollutions carried into it by storm water. Forty-two persons inhabited nine houses on this watershed, six of these houses have no privies, and none have any suitable drainage arrangements. On this watershed, in a house without a privy, 700 yards from and above the service tank, there occurred during October and November, i897, four cases of enteric fever. Close to the house is a pond which served as a receptacle for all slops and liquid refuse from the cottage, and at the time of Dr. Low's two visits to it " t h e surface of the ground round about the house and near the pond was profusely littered with human excrement." Previous to the arrival of a nurse "all the fluid