Brian Altonen, MPH, MS

An almost similar, though not so fatal, an epidemic arose at the village of Winterton. I may give an example of the commencement of this epidemic without further following its details.

A row of four houses were supplied with water from a pump well, within 14 feet of which were situated one open drain, one open ashpit, two pigsties, three privies, and one cesspool, all from 18 inches to 3 feet on a higher level than the well

In No. 1 there lived 3 persons, 2 of whom had fever.

2        „             4     „            4           „          „                and 1 died. Q 7 7

3                         1                  1

4                        4                   0

The people in No. 4 would not drink the water because it had a bad taste, and therefore escaped the fever.

.

Guildford affords another example of how much influence dirty water has in producing enteric fever. This is a town which, in the year 1861 had a population of 9,000 inhabitants living in 1,675 houses. The town stands on chalk on the side of a hill. The stratum of chalk afforded a natural drainage for the town, all sewage being conducted into cesspools, which drained themselves into the chalk, and therefore remained nearly always dry, and were never known to be offensive. There was no system of drainage at Guildford at time of outbreak. The water supply was derived from several sources—

1st. From an old well sunk in chalk at the bottom of the hill, from which water is pumped by a water-mill.

2nd. A new well from which water was pumped to the upper parts of the town by engine power.

3rd. From private wells attached to the houses.

Nine hundred and twenty-eight houses are supplied from the first two sources, 747 from the private wells.

Some enteric fever always is present in Guildford in its poorer parts.

The outbreak occurred in the last days of August in the upper part of the town where it had not previously prevailed, and where the wealthier part of the population reside. What were the influences to which the infected districts became exposed, which were followed by the fever? There were in all 264 eases of fever, of these 177 were in the 330 houses supplied by the high service water supply, 30 in 598 houses on the low service water supply, and 57 in 747 which received no water from the public water works. This shows at once that those receiving the high level supply were more liable

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to enteric fever than any others; and excluding the ordinary cases, and the case of children who attended school in the infected districts, but who resided elsewhere, nearly all the fever arose among those drinking the high service water which was drawn from a reservoir in the high part of the town, kept filled from the well by the pumping engine on the low ground.

Up to August 1st these people had a constant supply of water from the high level reservoir; on that day the engine broke down, and the water supply from the old well and wheel was resumed. At this time there was still some water left in the high level reservoir, which was left there exposed to the influences of the heat of August weather, which would promote decomposition of any organic matter it might contain. On the 17th of August the water-wheel broke down, and thus the second supply to the occupiers of the high level district failed. Half a loaf being better than no bread, the small residue of dirty water was supplied to those houses, and then followed the fever. The well from which the water had been pumped was found to be contaminated with sewage, which was comparatively harmless until concentrated and acted upon by exposure to the summer heat while it lay undisturbed for nearly three weeks in the reservoir.

Two points are here illustrated:—1st, how sewage contamination poisons water; and 2nd, how this poison is increased in intensity by decomposition and concentration.

An outbreak of enteric fever at Islington has been shown by Dr. Ballard to have depended upon the sewage contamination of milk from a dairy-yard pump, which had been used to increase the value of the milk to the dairyman, at the expense of the health and lives of his customers.

Of 2,000 families resident within a quarter mile radius of the dahy-yard, 142 were supplied with milk from this dairy, of these 70 were invaded by enteric fever within 10 weeks.

“It is remarkable,” says Dr. Ballard, “how typhoid picked out the customers of this dairy; thus in one long road and a street issuing from it, at a distance of a mile or more from the dairy, it supplied 3 families—of these, two had typhoid. It supplied 4 families in a neighbourhood of about 70 houses—of these, 3 had typhoid; it supplied 4 families in a row of 9 houses, typhoid occurred in 2 of them; and in the other 2, cases of a mild febrile character occurred.”

And so on in many other instances. Dr. Ballard also shows that only those who consumed the milk were affected by fever, and of those who worked in the dairy-yard and did not use either the dirty milk or dirty water none had the fever. On examination, Dr. Ballard found that the pump from which the milk was, I believe, undoubtedly watered, was contaminated by sewage infiltration into the tank from which the pump water was derived.

Within the last few weeks similar examples have been presented by Dr. Russell, who showed that of 72 families in 5 streets supplied by a dairyman in whose family enteric fever prevailed, 22 had fever; and in 32 families supplied by this dairyman there arose 36 cases of fever.

In conclusion Dr. Russell remarks:

“I regard this as an extreme illustration of what most frequently happens where the sale of articles of food is conducted in close connexion with families, and all their attendant ailments. Milk is, from its composition, a peculiarly favourable medium for the propagation of the germs of disease, and particularly of enteric fever, and it is very likely that many apparently inexplicable outbreaks of enteric fever in families are caused by milk, or even solid food contaminated in the retail shops, especially among the poor. It is a very common practice in all parts of the city for parties to live and rear families in rooms behind shops, through which often the sole access lies, and in which groceries, milk, provisions of all kinds, sweetmeats, fruit, <;tc, are sold. These shops are ‘served’ by one or both parents, or by some grown-up child, and when infectious disease enters such a family, it cannot fail to be the source of quite peculiar risk to the public. I have been so much impressed with this by a series of cases in point, that I applied to Mr. Lang, the Procurator Fiscal, to ascertain what legal powers existed to deal with them. Mr. Lang writes his opinion that persons situated as described in the various instances given in your letter have not proper lodging or accommodation. It will, therefore, be possible by this and other provisions of the Public Health Act to deal with such cases, so as to save the poorer classes from the obvious dangers of contagious sickness in such circumstances. I have, therefore, issued to the Sanitary Inspectors an instruction that systematic attention be paid to the health of all families living in the circumstances described, by a more routine visitation than from the character of the people and the locality might be thought necessary. Any case of infectious disease discovered must be specially and immediately reported to the medical officer. The greatest care is to be taken not to injure the interests of the parties referred to by unnecessary publicity in the discharge of this duty; but at the same time there is a very obvious danger to the public from thenprivate sickness, arising from their mode of living, which quite warrants the interference of the department.”

“The fatal activity of milk as a cause of disease has also been most carefully and scientifically investigated by Dr. Taylor, of Penrith; Dr. Bell, and Dr. Thome. It has been shown that not only

VOL. VII.—NO. I. H 2

typhoid but small-pox, scarlatina, and even cholera, have probably been oommunicated to people, through the medium of milk. It is, therefore, of the utmost public importance to inquire into the sanitary condition of the cow-sheds and dairy-yards.

“The following is a graphic description of the dairy-yards in the south side of the city, by Mr. Benson Baker, of London, who published some notes on a sanitary tour through Dublin about two years ago. Any one who will take the trouble to investigate the matter now will find it equally applicable :—’ In the most densely-populated and fever-infected district, in close vicinity to the Corporation manure depot in Marrowbone-lane, are to be found the cow-sheds and dairy-yards of Dublin. These yards, like the neighbourhood, are abominably filthy; manure is allowed to accumulate in heaps, from which may be seen small black fetid streams flowing into the open streets. The effluvium from these yards is absolutely poisonous, and is only equalled by the atmosphere in the cow-sheds. In this district man and beast alike fall easy victims to preventable disease.’ Speaking of the condition of the cows, he adds—’ Dr. Cameron says that the loss from pleuro-pneumonia sustained by Dublin dairymen is at least 10 per cent., yet the dairymen cannot be convinced that the disease is contagious, and, therefore, unless under compulsion from the sanitary authorities, they never disinfect their premises after the removal of diseased beasts from them.’ The vital powers of the cows are lowered by their constant respiration in close fetid stables. In some of the sheds the cubic space allowed for a large cow is less than the minimum—viz., 300 cubic feet of breathing room— allowed a man in a registered lodging-house. The cows were so close to each other that it was impossible that they could all lie down together. On questioning the owner on this point he facetiously replied, ‘Gorrai, sir, they take it turn about.’ This repartee might excite a laugh if the occasion of it did not inflict cruelty on the beasts, and tend to affect the people with disease. It is not surprising to learn that milk obtained from cows herded together in such unsanitary conditions, not only conveys foot and mouth disease, but typhoid and other zymotic diseases to the consumer.”

I have little doubt that many cases of fever and diarrhoea are produced in a similar way in Dublin, by the sewage contamination of milk. Any one who visits a Dublin dairy-yard, must have been convinced that the milk derived therefrom must run great chances of sewage contamination of some sort, for more fearfully filthy places can scarcely be imagined. Where causes of enteric fever and typhus co-exist, both diseases will arise at same time and sometimes even in same person, as I have shown to be the case in an account of fever at 50 Bishop-street.—Irish Hospital Gazette.

While on this subject I may mention that not only enteric fever, bufc cholera, small-pox, and scarlatina, are liable to spread in this way. I have treated dairy-maids for smallpox and scarlatina; and I regret to find on Dr. Mapother’s street list of cholera in Dublin, in 1866, which he has kindly lent me for the purpose of this lecture, that many dairies are included as having been invaded by this disease. Dr. Taylor has demonstrated how scarlatina was spread in Penrith by means of milk, and similar observations have been made by Drs. Bell and Thorne. I believe I narrowly escaped a visitation of cholera in my own house from a similar cause in 1866. It is to be hoped that if, notwithstanding Dr. Cameron’s efforts, our dairymen still persist in diluting our milk they will confine themselves to Vartry water. Dr. Reynolds has shown you how to distinguish in many ways good milk from bad, but unfortunately no means is as yet known for distinguishing milk poisoned by disease germs. The same conditions which favour the spread of enteric fever, also favour the spread of diarrhoea, and in point of fact many deaths of enteric fever, especially in children, are registered as cases of diarrhoea. Enteric fever is a disease of summer, when the decomposition of sewage matter is favoured by the high temperature. Additional proof of the constant influence of poisoning by sewage matter is drawn from the Reports of the Medical Officer of the Local Government Board (formerly of the Privy Council) of England, where in every instance where a town is reported as infected by enteric fever, we find that the arrangements were such that tho inhabitants were poisoned by their own sewage.

Relapsing fever is generally believed to be the direct product of famine, but being contagious may communicate itself to well-fed persons. It is as Dr. Stokes informed you, when speaking of the great famine fever, frequently followed by typhus.

Cholera.

In close relation to enteric fever as to causation, stands cholera. The most constant condition connected with the spread of cholera is an impure water supply, or a supply contaminated with sewage matter. I could give numerous instances of this, but shall confine myself to the one of London, where terrible experiments have been carried out on a most gigantic scale, which prove the relation between impure water supply and cholera I do not mean to say, positively, dirty water produces cholera, but it certainly promotes it, whether by containing the germs of that dire disease, or by merely affording a suitable and apparently necessary soil for the disease to grow upon.

The conditions which are essential to the production of whooping-cough are at present unknown, but the constancy with which it follows measles, points to the fact that what will control the latter will also control the former. Dr. Moore has shown how whooping-cough prevails in winter, measles in summer—the former following the latter and being aggravated by the effects of low temperature, favouring chest affections generally. No condition is yet known essential to the production of small-pox, but this is the most preventable of all Zymotic diseases by the simple and certain method of vaccination, so certain and safe a measure, that everyone is convinced of its certainty and safety except a few misguided and wrong-headed people who are more to be pitied than feared, and who should for the safety of society be handed over to the Commissioners who take care of the welfare of persons of weak intellect.

If other instances were required to show the value of sanitary measures, they could easily be produced. I will only mention two others as being derived from our own city. The cases of trismus iiascentium, or nine days’ fits, arising in infants in the Lying-in Hospital which have been I might say, annihilated by the preventive measures of ventilation and cleanliness first instituted by Dr. Clarke, and thus described in Dr. Churchill’s able work on diseases of children:—

“No institution as far as I know has ever afforded such ample experience of the disease as the Dublin Lying-in Hospital, before the improvements in ventilation and cleanliness introduced by the late Dr. Joseph Clarke, to whom we are indebted for the best description of the attack. Dr. Joseph Clarke enumerates three especial existing courses of the disease—first, impure air; second, neglect of keeping the infants clean and dry; and third, irregularity of living on the part of the mothers, especially the abuse of spirituous liquors. At the end of the year 1782, of 17,650 infants born in the Rotunda Hospital 2,944 died within the first

fortnight, or nearly every sixth child, and that owing to trismus. After the precaution he (Dr. Clarke) adopted the same pure and adequate ventilation in the hospital, out of 8,033 born alive, only 419 died in the hospital, or only 1 in 19 J. During Dr. Collins’ Mastership, of 16,654 infants born there were only 37 cases of trismus. Here is a splendid instance of the results of preventive medicine.”

The other is the case of puerperal fever, a disease originating in the overcrowding of parturient women, as referred to in Dr. Farre’s letter, quoted in the commencement of this lecture, which I think is very well shown in Dr. Evory Kennedy’s work on this subject and the truth of which I believe has been fatally demonstrated in the Dublin Lying-in Hospital, but which, thanks to the reforms introduced by the late Dr. Collins, to the energetic efforts of the present Master, Dr. Johnston, and to the knowledge of defects pointed out by Dr. Evory Kennedy, is not likely again to afford the opportunity for demonstrating the dependence of this disease on bad sanitary arrangements.

Puerperal fever can, I believe, be almost if not altogether annihilated, like the nine days’ fits,by isolation of the mothers either by separate buildings, as suggested by Dr. Kennedy, or by the complete isolation of the various wards by some other means.

Having shown the chief, original, and promoting causes of zymotic disease, it is manifest that the remedies are—

1. In building new towns or villages to select healthy sites.

2. Proper drainage, both house drainage and general drainage.

3. To prevent old ruinous and dirty houses from being inhabited, and to prevent new houses from being constructed so as to be injurious to the health of their inhabitants. Mr. Henderson will point out in his lecture how this is to be effected.

4. To prevent overcrowding either in houses or districts. This must be accomplished by constant inspection of all houses inhabited by the poor, by the regulation of the width of streets, the promotion of open spaces within towns, and by the breaking up of closed courts, and the making of wide thoroughfares through closed up neighbourhoods.

6. To promote cleanliness—1st, By the employment of all legal powers to compel and assist in the removal of dirt; and 2nd, To educate the people to believe that” cleajiliness is next to godliness.”

7. To provide proper accommodation for the sick at all times, and also during epidemics:—(a.) By proper hospital accommodation at all times. (b.) By proper means of bringing patients to hospital, (c.) By the provision of special hospitals or wards, in connexion with general hospitals, to be used only in time of epidemics, (d.) Refuges where the healthy can be separated from the sick until the sick can be removed to hospital, and the houses or rooms they occupied cleansed and disinfected, (e.) The provision of accommodation for convalescents from zymotic diseases in convalescent homes. (f.) Proper and systematic disinfection of all places where sickness prevails or has prevailed.

These must be all accomplished by means of a well organised sanitary system, and I am sorry to say such a system exists in but few large towns, not at all, I may say, in the country, and scarcely anything worthy of the name of organization is at present to be found in Dublin. The treatment of the sick and the prevention of disease should be under the same department, which should also have under its control all matters for the relief of the poor, registration of births and deaths, and the performance of vaccination. Each large district should be under a Chief Medical Health Officer and every dispensary district should have for its Sanitary Officer the dispensaiy Medical Officer acting under-the Chief Officer of the district. The Chief Officer should have almost absolute power, and should be only appointed with the consent of, and also removed by the chief sanitary authority of the state, namely, the Local Government Board. The absurdity of placing the administration of sanitary matters under the absolute control of Committees of Town Councils and Poor Law Guardians, many of them frequent offenders against sanitary law, is so great, that it will be at once perceived by every intelligent and thoughtful person.

I wish now to return my thanks to those who have given me their assistance in collecting materials for this lecture, namely, to Mr. Simon, the Medical Officer of the Privy Council; Dr. Burke, Medical Superintendent of the Irish General Registration Office; Dr. Ballard, of the English Local Government Board; Dr. Mapother, Medical Officer of Health for this city, and Dr. Maunspll, the able and energetic Secretary of the Poor Law Medical Officers Association. I have endeavoured to fulfil my difficult task to the best of my ability, and I trust that any shortcomings may be excused, and that you will believe that I have done my best to make a grave medical subject as little unpleasant and as interesting and useful as possible.

DIAGRAM IV.

Showing the Comparative Mortality from the seven principal Zymotic diseases during 9 years, from 1864 to 1872 inclusive, in the City of Dublin.