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"this instructive picture" is Part 10 of "The Capital of the Poor Man" series.
Below is the web version of Part 10.
Below that are references, primary source materials, documents, and pictures.
“this instructive picture”
1890 - 1891
A grosser or more culpable sin against the health of a populous community could scarcely be portrayed by any other wood cut of the same dimensions — about one-third of a page in size. It is almost as outspoken a charge against the fidelity of the local health officials as if they had been visited with an indictment of the Grand Jury, and reminds us of some of the outline-drawings of PRIDGEN TEALE’s primer on Dangers to Health, published about twenty years ago. No sanitarian who is engaged in teaching or in lecturing upon the prevention of infectious diseases, can afford to be without a copy of this instructive picture.
The Journal of the American Medical Association, January 30, 1892.
This section discusses the Typhoid epidemic of 1890 and 1891 in the City of Lowell. The effects on the residents of the city, the efforts to control it, and the work to identify the source of the outbreak and prevent future epidemics are chronicled.
An act of the Massachusetts Legislature in 1878 prohibited the dumping of sewage into a river if its water was used for drinking. The Connecticut River, the Merrimack River, and the section of the Concord River in Lowell were excluded from this prohibition. This exclusion was based on the idea that they were too large and swift for contamination to be a problem. What actually happened was that corporate interests convinced legislators that this was a fact when there was no scientific support for this mistaken assumption.
While the Merrimack River was crucial for Lowell and other Merrimack Valley cities and towns, in other ways it made getting drinking water and discharging sewerage too easy. Why look for other sources of water when you have a beautiful river running right through your city? Why build more expensive sewerage infrastructure when you can just dump everything into that beautiful river?
Typhoid fever: endemic and epidemics
Typhoid was endemic in many places during this period of history and, under certain conditions, the disease could reach the level of an epidemic in a particular area. Typhoid fever is caused by a gram-negative bacterium Salmonella enterica serotype typhi (S. Typhi). Typhus and typhoid fever are completely different diseases, although their symptoms are similar. The name is derived from the Greek word for smoke or cloud because one of the symptoms is a “cloudy mind” or “brain fog.” Other symptoms include poor appetite, headache, generalized aches and pains, fever as high as 104 degrees, lethargy, diarrhea, and abdominal pain. Typhoid is spread by eating or drinking food or water contaminated with the feces of an infected person. Only humans can be infected with this particular type of Salmonella bacteria.
In 1880, German pathologist Karl Joseph Eberth discovered the microbe that causes for typhoid fever, and it was first cultured in 1884 by Georg Theodor August Gaffky. 1n 1890, the year of the outbreak in Lowell, there was no vaccine of cure. Mary Mallon, known as Typhoid Mary, was an asymptomatic carrier, and in 1907 was the first asymptomatic carrier in the United States to be identified. She transferred the disease to families that she cooked for in New York.
While germ theory, including understandings of the role of certain microbes in water-borne and food-borne diseases, was gaining wide acceptance among scientists and physicians in 1890, the general public’s understanding lagged behind. This meant that common beliefs and behaviors were not changing with the new scientific understandings. Unfortunately for the public, the understandings of government officials and others with the power to make changes were not keeping up with science either. We will see that the actions and inactions of public officials in Lowell and other cites upriver concerning the water and sewerage infrastructure, and the unregulated decisions of private companies, put residents in the city at great risk. We will also see that changes in beliefs, behaviors, laws, regulations and public services based on science prevented illness and saved lives.
An epidemic and an investigation
Søren Kierkegaard (1813 – 1855) wrote that “Life must be lived forward, but it can only be understood backward.” Some form of this quote popped into my head as I was trying to write about the typhoid epidemic in late 19th century Lowell. In my mind at first, this story began with the identified source of the epidemic; however, by the time the general source was suspected and, later on, the specific source was identified, the epidemic was already abating. So, while the source came first in causing the epidemic, identifying the source came last. The epidemic had to be understood backwards then and now while it was lived forward by the residents of the City.
Another factor in my own thinking that initially interfered with my attempt to think coherently about the epidemic was my understandings of John Snow’s work during a London cholera outbreak in 1854. At first, my model for understanding the Lowell pandemic was influenced by my understandings of the London epidemic. Without belaboring the comparisons between the two epidemics, the key difference that affected my thinking was that Snow identified the specific source of the outbreak and persuaded London officials to take a specific action to stop it (i.e., removing the handle on the Broad Street pump), while Sedgwick narrowed down the possible general source of disease and told Lowell officials how to deal with it (avoid or boil city water and avoid canal water) before the specific source was identified. In other words, discovering the specific source of the typhoid outbreak did not end it, but the discovery was critical in showing ways to prevent further outbreaks in Lowell and other cities and towns. A similarity is that both Snow and Sedgwick made painstaking efforts to understand, identify, and end the epidemics that confronted them.
Typhoid cases: Autumn & Winter 1890/1891
The month of August 1890 saw a normal number of typhoid fever cases in Lowell (15 cases, 6 deaths). The previous August (1889) saw 17 cases and 5 deaths. During September 1890, the city saw a slight increase with 27 cases and 10 deaths. In October, there was another increase to 69 cases and 10 deaths. Then in November of 1890, physicians and city officials noticed a troubling increase in the number of cases of typhoid and typhoid-related deaths with 122 cases and 28 deaths. It has been estimated that by the time the epidemic ended, the actual number of cases exceeded 700 as it is likely that many cases went unreported. With an 1890 population of over 77,000, almost 1% of the city's population was affected with the disease.
From Sedgwick (1891)
In normal years with endemic levels of the disease present, cases of typhoid would typically decrease in November because of the colder weather. In November 1890, numbers did not decrease in Lowell but instead spiked to epidemic levels. The timeline graph below was photographed by the current author at the American Textile Museum’s library and archives, which is no longer in Lowell; however, I have not found it in any of Sedgwick’s published reports. Although I do not have any direct evidence to support this, I believe that the diagram below is one of the illustrations that Sedgwick thought should have been included in the published reports, but was not.
In one of the published reports, Sedgwick wrote that
I began a thorough inquiry and on April 4, 1891 presented to the Water Board of the city of Lowell a full Report, illustrated by maps, diagrams and photographs [italics added]. The text of this report was soon after published by them, but without the accompanying important and instructive illustrations [italics added]. (See A Report upon the Sanitary Condition of the Water Supply of Lowell, Mass., presented to the Water Board of Lowell, April 10, 1891, pp. 1 - 54. By William T. Sedgwick. Lowell, Mass. 1891.) An abstract of this report, but also without the necessary illustrations [italics added], appeared in the "Boston Medical and Surgical Journal," 1893, pp. 397-402, 426-430.
A modified detail of the diagram that was published four years later
The published diagram
Below, I used the same timeline graph and added two vertical red lines at November 1889 and November 1890. While we see Boston’s per capita cases decreasing where the graph line crosses the red lines, we see the Lowell cases increasing.
Typhoid timeline graph with red vertical lines at November
At the time, there were five distinct water systems in Lowell; the city water from the river, the canal water from the river, wells, a reservoir not used for drinking water, and spring water bottled from private springs. Of the five water systems, the city water and the canal water were initially suspected of spreading typhoid while the other water systems and also milk supplies were ruled out as sources of the disease. Many residents who used well water in the warmer months switched from well water to city or canal water when the weather got colder. In 1890, at the same time that this switch was happening, the river water was being contaminated with typhoid bacteria upriver. So, while the safer wells were being suspended for the season, infectious microbes were being introduced not too far away. The numbers began to decrease in December, but stayed high through March.
Lowell’s recognition and reaction
At a regular meeting of the Lowell Board of Health on December 2, 1890, “Agent Bates reported, that there had been 122 cases of typhoid fever reported during the month of November.” Of those typhoid cases that month, 28 resulted in deaths.
Minutes of the Lowell Board of Health, December 2, 1890
The Lowell Sun, December 20, 1890
The state of Massachusetts’s response
The Merrimack River water had been chemically analyzed by the state regularly and recently. However, when the state board of health was notified by Lowell of the spike in cases, William Sedgwick, a biologist for the state and a professor at the Massachusetts Institute of Technology, was sent to Lowell to determine if the increase in typhoid was caused by a change in the chemistry of the river. The professor had been to Lowell previously to examine the water, so he was familiar with the city and its water sources. Two chemical analyses were made of the Merrimack River water. After these chemical studies were conducted, the test results revealed the water to be “reasonably pure.” But, of course, a chemical analysis was not the same as a bacteriological analysis. The water was receiving some filtering, enough to make it appear safe, but not enough to remove potentially harmful bacteria.
During the latter half of December, Professor Sedgwick began conducting a bacteriological examination of the microbes found in Merrimack River water at various places and outlets. The samples had to be incubated for several weeks before it could be determined whether typhoid was present.
In addition to the bacteriological investigation of the water, there were house-by-house visitations of the dwellings of 550 of the typhoid cases. The form below was developed to record information about each individual case of typhoid fever.
An 1891 map of Lowell to which Sedgwick has plotted “the approximate location of 230 cases of typhoid fever possibly attributable to the use of canal water. Sept. 1, 1890 – Feb. 1, 1891”
Detail from Sedgwick’s map. Red line on original, pointing to “Intake of water supply” labeled on map
A full report given to the Water Board of the City of Lowell by Professor Sedgwick in early April. Neither of the maps, above or below, were included in the report, however, they are instructive for understanding the epidemic. The larger red circle on the left of the map below marks the area in North Chelmsford where Stony Brook enters the Merrimack River. This was identified as the area where the original cases introduced the typhoid germs into the river as will be discussed in detail below. The smaller red circle marks the same area that is in the detail from Sedgwick’s map above, which is the intake for the water supply for Lowell.
A different version of Sedgwick’s map. Red circles added.
In December, the number of cases began to decrease from the November 1890 spike. The numbers continued to decrease during the first three months of 1891, and returned to endemic levels in April 1891. High concentrations were no longer being introduced a couple of miles upriver and the pipes were being flushed out with cleaner water. In addition, city officials issued boil water notices, do not drink signs in were posted mills, and people were switching water sources, including the switch back to well water as the warmer weather came.
The source of the epidemic
While it was important that the source or sources of the epidemic be identified at the time, the identity of the human sources, in retrospect, don’t matter. The water and sewer systems along the Merrimack River were going to continue to be the source of endemic and epidemic diseases until they were fixed using the public health, scientific, and engineering knowledge available at the time. The unfortunate and unwitting sources in 1890 were victims and were not responsible for the epidemic.
Professor Sedgwick concluded that it was the city water, not the canal water, other water sources, or milk that spread the disease in this case. He wrote that that “all the phenomena of the epidemic, as well as the constant and long-standing excess of typhoid fever in Lowell, are attributable to the use for drinking purposes of the infected water of the Merrimack River.”
Just as Professor Sedgwick had to start with the infected patients in Lowell and understand the history backwards, he had to trace the bacteria by looking upstream. Looking upriver, Sedgwick stated that cities were polluting the Merrimack, but in this period of time, the numbers of cases of typhoid in these cities were actually lower than in previous years. He identified a “small epidemic of typhoid fever upon a feeder of the Merrimack less than three miles above the intake of the Lowell Water Works” in the village of North Chelmsford. The “feeder of the Merrimack” was Stony Brook in North Chelmsford.
The small epidemic at North Chelmsford was “confined to three families” and affected eight or nine cases, one of which was fatal. However, he concluded that not all of these cases infected the river:
We have concluded above, from the intrinsic evidence of the epidemic itself, that the infection underlying it, must largely have fallen upon the city, as a sudden blow, somewhere within the last two weeks of October. I believe that the principal blow was dealt by Case No. IV, who, as we have seen, infected the river at North Chelmsford within the two weeks previous to Oct. 27, 1890.
The diagram below, which was not in any published reports that I have found, shows the weekly morbidity and mortality rates over the course of the epidemic. This timeline graph also includes the four North Chelmsford cases, with case numbers and initials, labeled “The Periods of Infection of Stony Brook.”
Another unpublished illustration photographed at the former American Textile Museum
Detail (lower left section) from the diagram above
It is interesting to note that initials of the four early victims were not used in Lowell report, but are used by Sedgwick in his state report. It is likely that while initials were used in the state report and the captions of the photographs, Lowell officials did not want the initials or the photographs in the report to the city.
“this instructive picture”
Conclusion: What was learned, what was done, what were the results?
Danger is as present with us in the daily routine of our peaceful lives as on the battle-field, only that the embodiment of danger is an invisible and intangible germ, instead of a fast-flying bullet. It flows beside us in the river, in our mains, from the taps in our houses; the germ of disease may not be in this pitcherful or in that, but it will find us some day if we continue to use the water which contains it.
Fourteenth Annual Report of the Board of Health of the City of Lowell for the Year 1891
This epidemic occurred in the midst of a paradigm shift in the understanding of public health and contagious diseases. Germ theory was becoming more accepted, the idea of self-purification of streams was losing its grip it light of the understanding of bacteriology, and more people were beginning to realize that we all live downstream, although that phrase was not used at the time. Unfortunately for the victims, this shift was not sudden across the society. While scientists, physicians, and others looking out for the public health were responding to the new findings, politicians and those with vested interests in the status quo were resisting change, especially if the change caused bad public relations or required an investment of money.
For example, the Massachusetts law that allowed municipalities to dump waste and sewerage into the Connecticut, Merrimack and Concord rivers, mentioned above, was based on self-interest and not on science. This state law was crafted in a way that acknowledged the danger of polluted water while still bowing to pressure from the corporations. According to George Chandler Whipple in 1908,
Intimately involved in the question of the longevity of the typhoid fever bacillus in water and sewage, is the old familiar theory of the self-purification of streams. Part truth and part error, the theory that "running water purifies itself” has lived through several generations, and still has a strong hold on the public mind. As its misapplication may do much harm, it deserves more than a passing notice.
Lowell’s elected officials could only do so much, and relied on bad advice that was reinforced by denial and convenience. In addition to having to listen to industrial interests, the pollution was coming from places over which they had no control. Although the drinking water was far from perfect by today’s standards, diseases of all kinds were prevalent and one could say that, unless there was an identified water-related epidemic, water was no more of a problem than many other potential sources of disease. For example, at the time, milk was also a prime suspect in typhoid and other diseases.
The Lowell Board of Health was sounding an alarm and its members were advocates for change. Although they had regulatory and enforcement powers in some areas such as privies, they had no power over the source of Lowell’s drinking water or the dumping of sewerage by people upriver. The Board seemed to be responsible for reporting bad news and micromanaging public health, but were out of the loop when it came to the level of making significant and lasting changes.
The Massachusetts State Board of Health was in many ways the best in the country at that time to respond to a typhoid epidemic. Even so, much of their science was new and still developing and their conclusions were often met with skepticism or rejection.
It seems that most Lowell physicians were recognizing and reported cases of typhoid to the Board of Health; however, some were reluctant to report cases. We can see evidence of this reluctance in the Lowell Board of Health meeting minutes from December 23, 1890, and again almost one year later in a letter to Lowell physicians dated November 25, 1892.
Minutes of the Lowell Board of Health, December 23, 1890
Fourteenth Annual Report of the Board of Health of the City of Lowell for the Year 1891
It is impossible to imagine what it was like to be alive in 1890. By today’s standards, it was grim, though at the time people faced the difficulties with strength and stoicism. At the same time, life expectancy was starting to move in the right direction. That trend, with the exception of the years of the Spanish Flu and World War I, has continued in a positive direction up to the present. In 1870, 1875, and 1880, life expectancy from birth was consistently around 39.4 years. In 1885 life expectancy was 41.1 and in 1890 it was 44.0. As a result of germ theory and the resulting discoveries, changes in beliefs, behaviors, laws, regulations and public services prevented serious illnesses and increased life expectancy. Eventually, it was realized the Federal government had a role in public health and that health problems did not begin and end at the borders of our cities and states.
While the focus here was on Lowell, the typhoid germs did not stop in Lowell, but continued downstream infecting Lawrence, nine miles down the Merrimack. Epidemics were not over in Lowell either. The outbreak in 1890 was repeated in 1892. After the second outbreak, Lowell ceased its use of the river water, had wells dug, and began using ground water supplies. Lawrence did more and did it sooner than Lowell by constructing a filtration plant, which was a significant step in the public health movement. The 2.5-acre filtration system cost the city of Lawrence $67,000 on a system and sharply reduced the outbreaks of typhoid.
The chart below was in an article that was in the The Journal of Infectious Diseases in 1910. This long-term study shows that cases of typhoid dropped significantly when Lowell changed from river supplies to ground-water. Lowell took two years to change over, so the two years (1895 – 1896) where both the old and new supplies were in use were omitted from the study. When Sedgwick and Macnutt looked at the five years before the changeover and five years after, they found a 78% decrease in the number of deaths from typhoid. There was an average of 97 deaths per 100,000 people per year in the five years before the changeover and 21 deaths per 100,000 people per year in the five years after the changeover. Lawrence’s earlier and faster switch form river water to a state-of-the-art filtration system had a similar result.
From Sedgwick and Macnutt, The Journal of Infectious Diseases, Aug. 24, 1910, Vol. 7, No. 4
Typhoid was by no means eradicated in Lowell or anywhere else at that point in history. Vaccines, antibiotic treatments, and the chlorination of water would come later. In addition, municipal water supplies were not the only way typhoid was spread, though they were by-far the most widely lethal way. So while typhoid would remain endemic in many areas, those places that took effective action based on scientific knowledge no longer experienced pandemics.
|8 16 1890 mortality for July|
|11 8 1890 report of deaths week|
|11 15 1890 2 obituaries|
|11 22 1890 report of deaths week|
|12 13 1890 St John's Hospital|
|12 13 1980 Report of Deaths week|
|12 20 1890 November health bulletin|
|12 20 1890 Report of deaths week 12 19?|
|12 20 1890 typhoid cause a puzzle|