THE FEVER ENDEMIC IN LOUISVILLE.*

By J. N. M'CORMACK, M.D., Secretary of the Kentucky State Board of Health.

SINCE the latter part of October last I have been engaged in the name of this Board in an investigation into the cause of an endemic of typhoid fever then alleged to be prevailing in the city of Louisville. In this work I have availed myself of the meagre health records of the city for the past sixteen years, have personally examined a number of the fever cases, and the premises where they occurred, have inspected the streets, alleys, topography, and natural and artificial drainage of the district especially afflicted by the disease, and personally and otherwise made special inquiries as to the method of construction, location, and condition of the vaults and wells, the source and character of the water and milk supply, and of other conditions and habits likely to influence the health of the inhabitants of this locality. To a lesser degree I have conducted similar investigations as to the health conditions of other portions of the city. In all this work I have had the hearty cooperation of many of the leading physicians of Louisville.

In consequence of the fact that physicians and heads of families are not required to report to the health officer each case of disease dangerous to the public health, it is impossible to give facts bearing on the history of typhoid fever in Louisville in previous years, except those furnished by the mortality tables. With four exceptions, which will be noticed, these tables have been obtained as far back as 1868, and they show the following death-rate from this disease: 43 in 1868, 33 in 1869, 75 in 1871, 82 in 1875, 53 in 1876, 44 in 1877, 72 in 1878, 86 in 1879, 96 in 1880, 146 in 1881, 114 in 1882, 106 in 1883, 145 in 1884. No health report was made in 1870, 1872, and 1873, and that for 1874 could not be obtained. In most of these tables deaths from typho-malarial fever were reported as typhoid fever, and to escape confusion this has been done by me for exceptional years. From these figures it will be seen that although this disease has attracted unusual attention from

* Read to the Kentucky State Board of Health, at its quarterly meeting, May, 1885.

the medical profession and the public of the city recently, the death-rate from it last year was one less than in 1881, and not greatly in excess of that of 1882 and 1883, and that on the whole the death-rate from this cause has slowly but surely increased with the years. These figures also show that, whatever the cause of the disease may be, it has taken up a permanent residence in Louisville, unless extraordinary efforts are made to drive it out. In this connection it would be interesting to know the location of cases, or at least of the principal number of cases, in former years, and whether or no the same house or locality has furnished successive cases year after year; but no means exist for obtaining this information, for the reasons stated.

As to individual cases of fever, my inquiries have only been in regard to cases occurring from August 1 to December 1, 1884, and had reference entirely to the character and cause of the disease. By means of blank slips for individual cases, information was asked from the attending physician on the following points in regard to each case: Name the location, date of attack, distance of vault from house, its depth and condition, condition of cellar, method of disposal of house-refuse and kitchen-slops, source of water-supply, source of milk-supply, whether or no the house in which the case occurred is in the flooded districts, whether or no it was possible with the facts at hand to trace the disease to a previous case of the same character, and, under the head of remarks, any other facts observed bearing on the character or cause of the disease. In this way such facts have been more or less perfectly collected in regard to 387 cases occurring within the dates mentioned, which I estimate to be about two-thirds of the cases occurring in that time. Of these 387 cases 247 were located in the "west end," a large majority of them within the fever district shown on the map, and particularly in the western portion of this district the remainder being scattered over other portions of the city. The condition of the vault is noted in 158 cases, being good in ninety-two cases, and bad in the remainder. It is uniformly stated, when reference is made to this point, that the vaults extend to the gravel formation. In a number of instances it is stated that the vault on the same or adjoining lots is from two to fifteen feet from the house; in many that it is

full, and in some that it is overflowing. In eight cases the water-closet was in the house. The condition of the cellar was noted in 143 cases, being good in 102 and bad in the remainder. The method of disposal of house-refuse and kitchen-slops is noted in 160 cases, being carted away, cremated, or otherwise properly disposed of in 16 cases, and thrown in the back yard, alley, gutter, adjoining lot, or fed to pigs, in 144 cases. The source of the water-supply is noted in 314 cases, being from hydrants in ten cases, from cisterns in six cases-four of these cisterns being located in the cellar-and from wells in 298 cases. The source of the milk-supply is not often stated in sufficiently definite terms for any satisfactory conclusion. Four of these cases were located in the flooded districts. In In many instances it is noted that pigs, fowls, cows, or horses are kept on the premises, and in very many that the back yards and alleys are foul. In a few instances it is stated that the premises are in good condition; but in such cases no note is made of the condition of the surrounding premises. In a number of instances more than one case is reported from the same house, and in three instances as many as four cases. The large majority of the cases are reported as mild in character and usually of short duration. In no case, so far as stated, could the disease be traced to a previous case.

From the Christian name in the reports the sex could be determined in 210 cases, and of these 91 were males and 119 females. The age is not usually given, but from conversations with physicians and my own observations I learn that a large proportion of the cases were in children.

In order that each fact brought out in this inquiry may be given its proper weight as a possible factor in the production of disease, it may be well here to make a brief statement of those facts in regard to the natural location and surroundings of the city, and of the customs and habits of its inhabitants, necessarily connected with its health history.

Louisville was first incorporated as a town by the Virginia Legislature in 1780, and as a city by the Kentucky Legislature in 1828. It is situated on the southern side of the "" Falls of the Ohio," in latitude 38° 3' and longitude 85° 30'. In 1830 it had a population of 10,341, which had steadily increased to 123,758 in 1880. The main portion of the city is built on an

alluvial plain, at an average of about fifty feet above low-water mark, and four hundred and forty-one feet above the level of the ocean. This plain is interrupted in the eastern and southern portion of the city by Beargrass Creek and its tributaries,

and south of the city is continuous with a district of swamplands several miles in extent. Much of the western, southwestern, and southern portion of the city was once studded over with stagnant ponds and marshes, many of the ponds being of considerable depth, and some of them still existing. These ponds were gradually filled with refuse from the city, usually without previous drainage, and over the surface thus filled a dense and often not overcleanly population has been crowded, with little or no provisions for preventing the further pollution of an already polluted soil. The character of the surface and subsoil formation is shown in Fig. 1, except that in many places the sand and gravel come much nearer the surface than the cut would indicate, and that the coarse gravel is usually not so near. The surface clay is mixed with sand, and on repeated tests I have found it quite porous. The subsoil is saturated with water under the entire city at a depth of from twenty-five to forty feet, as shown by the level at which water stands in the wells and privy-vaults. The dip of the under

lying formation is from southeast to northwest, and the current or drift of this underground lake of soil-water, which furnishes a never-failing supply for the hundreds of wells, is always slowly flowing in this direction.

There are about eight hundred public wells in the city, of which five hundred are of brick and stone, sometimes lined with cement, as represented in Fig. 2; two hundred and fifty of cement, as represented in Fig. 3; and fifty tubular or bored

wells, as represented in Fig. 4. Figs. 2 and 3 also show some of the methods by which impurities from the gutters find their way into the wells. For the drawings from which these cuts are made, I am indebted to the city engineer, Mr. R. T. Scowden.

FIG. 4.