Public Health

1913 The Lancet  
—This report deals with the causation of 69 cases of enteric fever notified in the borough of Rochester during the summer of 1912. The borough is divided by the river Medway into the ancient city of Rochester on the south and the modern town of Strood on the north, the latter contributing some 13,500 out of a total population of about 31,500. With two exceptions all the notified cases occurred in Strood ; the first was reported on August 2nd ; 26 cases followed in the week ending August 10th.
more » ... ding August 10th. and 21 cases in the following week. Cases in relatively small numbers were reported during the succeeding six weeks, after which the epidemic came to an end. Eight cases were fatal. Those attacked belonged principally to the working classes ; 33 were males and 36 females ; 29 were under and 40 over 15 years of age. Dr. Wheaton found that on marking the position of the invaded houses on a spot map of the district they could not well have been more scattered all over Strood than they were, nor could the enteric fever have been more widely distributed in that area. The sufferers were served by eight milk-supplies, some of which were also distributed in Rochester ; quite half the persons attacked had condensed milk only, so that it seemed very improbable that milk was the medium of infection. There was no suspicion attaching to shell-fish or other articles of food likely to cause infection. Sewers could hardly be implicated directly. Strood has no sewerage system in the ordinary sense of the word ; most dwellings drain to cesspools, the contents of which soak away into the chalk or the superficial deposits overlying the chalk. As regards water, however, Strood has a different supply from Rochester, and all the invaded houses in Strood were supplied from the Strood waterworks. The water is distributed in a high-and a low-level supply, and the enteric fever incidence was practically the same over each area of service. On a theory of water causation the infective material must have been present at the sourcei.e., in the water of the waterworks well. The report deals in detail with the origin of the water supplied from the Strood waterworks and its liability to pollution. The water is obtained by pumping from a well 114 feet deep, which is supplied by an adit that has been formed by following up and enlarging a large fissure in the chalk. This has been opened up for a distance of 115 feet, and water enters it at its far end and from numerous subsidiary fissures which cross it more or less at right angles. By tracing the direction of these fissures it is possible to obtain an indication of the surface areas from which the water has been derived. On these areas, and in the neighbourhood of the well, are numerous soak-away cesspools connected with water-closets and drains known to be defective. The only cesspools which have been made watertight with the object of protecting the well are the four in, or close to, the waterworks site, while there are at least 50 soak-away cesspools within a radius of 300 yards from the waterworks. Other sources of possible pollution presented themselves, such as the manure on the adjoining allotment grounds, which may get into "swallow-holes" " and so to fissures in the chalk. A case of enteric fever was ascertained to have been nursed in a house near the well between May 2nd and June 20th, 1912, and it was clear that enteric fever infection had passed into drains and cesspools in the neighbourhood. LTnusually heavy rainfall occurred during June, 1912, and the water-level in the adit was high during the early part of July, so that it seemed probable that the outbreak had resulted from infected material washed down into the adit during the latter month. On August 12th Mr. S. I. Pritchett, the medical officer of health of Strood, and the borough surveyor decided that some chemical treatment of the water was necessary, and on August 17th the mains and reservoirs were disinfected by the addition of "chloros," to form tIP. 1 London : Wyman and Sons, Fetter-lane ; Edinburgh: H.M. Stationery Office ; Dublin: E. Ponsonby. Price 4d. dilution of 1 in 20,000, and this was followed by the continued addition up to Oct. 22nd of 1 part of chloros " to 100,000 of the water in the low-level reservoir through which the whole supply passes previous to its distribution. After Oct. 22nd the quantity of " chloros " was reduced by one-half. Within six days of the first addition of ° ° chloros " the samples examined, which, however, were few in number, showed that the low-level reservoir water was practically sterile, and this was also the case with further samples examined in October. The treatment gave rise to complaints from the consumers on account of the taste of the water, and Dr. Wheaton points out the dangers of relying upon continuance of the treatment as a safeguard against a sudden and relatively heavy infection of the water, such as might occur in the circumstances to which the waterworks are exposed. Moreover, the possible action of chlorine compounds on pipes, valves, and taps, which is stated already to have given trouble in the case of taps at Strood, has to be borne in mind. VITAL STATISTICS. HEALTH OF ENGLISH TOWNS. IN the 96 English and Welsh towns, with populations exceeding 50,000 persons at the last Census, and whose aggregate population at the middle of this year is estimated at 17,852,766 persons, 8864 births and 4623 deaths were registered during the week ended Saturday, May 31st. The annual rate of mortality in these towns, which had been 13-9, 12-8, and 13-4 per 1000 in the three preceding weeks, rose to 13-5 5 per 1000 in the week under notice. During the first nine weeks of the current quarter the mean annual death-rate in these towns averaged 14-4 per 1000, against 14 3 in London during the same period. The annual death-rates in the several towns last week ranged from 57 in Eastbourne, 5-9 in East Ham, 6-0 in Ilford, 6-6 in Southend-on-Sea, and 6 7 in Walthamstow, to 20'9 in Stockton-on-Tees, 21-9 in Oldham, 22-2 in Stoke-on-Trent, 24 -5 in Walsall, and 24 -7 in Wigan. The 4623 deaths from all causes were 50 in excess of the number in the previous week, and included 367 which were referred to the principal epidemic diseases, against 325 and 330 in the two preceding weeks. Of these 367 deaths, 117 resulted from measles, 91 from whoopingcough, 81 from infantile diarrhoeal diseases, 41 from diphtheria, 23 from scarlet fever, and 14 from enteric fever, but not one from small-pox. The mean annual death-rate from these diseases last week was equal to 1'1, against 0-9 and 1 ° per 1000 in the two preceding weeks. The deaths attributed to measles, which had been 151, 137, and 133 in the three preceding weeks, further fell to 117 last week, and caused the highest annual deathrates of 1-6 6 in Wolverhampton, 2'0 0 in Aberdeen, 2-3 in West Bromwich, 2-8 in Smethwick, and 3-0 in Edmonton. The deaths referred to whooping-cough, which had been 83, 65, and 67 in the three preceding weeks, rose to 91 last week, and included 30 in London, 6 in Leeds, 5 in Manchester, 4 in Liverpool, 4 in Newcastle-on-Tyne, and 3 each in Norwich, Stoke-on-Trent, Birmingham, and Sheffield. The fatal cases of diarrhoea and enteritis (among infants under 2 years of age), which had been 79, 71, and 70 in the three preceding weeks, rose to 81 last week ; 20 deaths were registered in London, 6 in Liverpool, 4 in Birmingham, 4 in Preston, 4 in Acton, and 3 in Bristol. The deaths attributed to diphtheria, which had been 40, 26, and 28 in the three preceding weeks, rose to 41 last week, of which number 12 occurred in London, 3 in Walsall, and 2 each in Portsmouth, Stoke-on-Trent, Birmingham. Bradford, Sheffield, and Rhondda. The deaths referred to scarlet fever, which had been 16, 22, and 21 in the three preceding weeks, were 23 last week, and included 4 in London, 4 in Birmingham, 3 in Tynemouth, 2 in Smethwick, and 2 in Newport, Mon. The fatal cases of enteric fever, which had been 12, 4, and 11 in the three preceding weeks, rose to 14 last week; 3 deaths were recorded in Manchester, 2 in London, 2 in Liverpool, and 2 in Bradford.
doi:10.1016/s0140-6736(01)42933-3 fatcat:uqtkyy4rsnhsfha25ugoyl3iee