Water carted into Nunney
Ballard noted that the number of fresh cases of the disease dropped suddenly after 5 October 1872. The Nunney Brook was still being contaminated with infected human excrement.
From 24 September water from an unpolluted source was brought into the village on carts every day for Nunney residents to use. Not everyone stopped drinking water from the brook though, out of habit or ignorance.
“It could scarcely have been expected that the brook water should at once have fallen entirely into disuse, that none of it should have been used by anyone in the village,” according to Dr. Ballard. “Such changes are never to be effected suddenly.”
Over a period of five weeks, 8 to 18 fresh cases a week had been reported. After twelve days of carting unpolluted water into Nunney, the weekly number of fresh cases fell to 5, and in the next week to one.
With the help of two local medical officers, Ballard was able to trace Nunney’s medical history back 28 years. The present medical officer, Mr Marsh, had held office for 15 years and his predecessor, Mr Cockey, for 13 years before that.
For these 28 years the local community had been drinking water containing excrement without being attacked with typhoid – with the exception of isolated cases. In Ballard’s view this showed that mere faecal matter will not give the disease unless it is contaminated with active typhoid bacteria (or ‘poison’, as he described it).
There were patients in 40 houses in Nunney, not confined to any particular part of the village, but distributed throughout all parts. Ballard verified that 73 patients had drunk water from the Nunney Brook and the other three had almost certainly done so. Those who had drunk nothing but tea or cider and those who obtained water from other sources had not fallen ill.
All who used filtered rain-water or well-water escaped, except one family who used the water of a well only four or five yards from the brook.To Dr. Ballard this confirmed that the disease was caused by drinking water polluted with active typhoid bacteria.
For the disease to grab hold of a community, it wasn’t enough to to have polluted drinking water, poor hygiene and a lack of sanitation. Typhoid is caused by eating food or drinking liquid contaminated by the faeces or urine of infected people.
There were no cases upstream from where the first patient had continaminated the water, with one exception – which in fact proved Ballard’s case. In this upstream case four children who lived upstream from Holwell fell ill.
They all went to school in Nunney and drank water from the Nunney Brook. Although two of the children fell ill during their holidays and sometime after the school had closed, they still constantly went in to Nunney to meet friends.
Two visitors to Nunney fell ill after drinking tea, which Dr. Ballard believed had been made with water from the Nunney Brook.
Introduced by a visitor
His overall conclusion was that typhoid did not develop independently as a result of poor hygiene or the right conditions. He found that for typhoid to cause an epidemic within a community, it had to be introduced by a visitor to that community through contamination of food or drink.
Further case studies of outbreaks of typhoid elsewhere in the country by Edward Ballard and others confirmed his findings.
“I think we may now safely believe that the presence of typhoid evacuations in the water is necessary,” according to Dr. Ballard. “Common faecal matter may produce diarrhoea, which may be febrile, but for the production of enteric fever the specific agent must he present.”
Ballard’s case study in Nunney and similar ones he conducted elsewhere became hugely influential.
Nunney became notorious in the medical world, as this extract from the British Medical Journal of 1874 shows: “In his annual report on the rural sanitary district of Frome, Mr. J. Parsons refers specially to the village of Nunney, which is characterised by its impure and insufficient water supply.”
“This place has already obtained an unenviable notoriety in sanitary literature by the widespread and severe outbreak of enteric fever which appeared there in 1872. The lesson of that outbreak appears, however, to have been disregarded by the sanitary authority; for, when Mr. Parsons wrote, he found that most of the inhabitants were using water derived from a stream polluted by the drainage of a village above, notwithstanding that a wholesome supply could with facility, and at a comparatively small cost, be brought into the place by gravitation.”
“No provision has been made for the isolation of persons suffering from infectious diseases, and the means at the disposal of the medical officer of health for hearing of such cases at an early date are so imperfect, that in many instances he is quite unable to stay their spread. The sick remain in overcrowded dwellings, and, when death ensues, the dead bodies at times occupy the general sleeping apartment of the family.”
In 1875 Parliament allocated funds to introduce a piped water supply in Nunney and Holwell, with public taps where local residents could get unpolluted water. They also instructed that proper toilets and main sewers should be installed in Nunney and Holwell to prevent sewage going into the Nunney Brook. In 1889 water was piped into the village from reservoirs at Gaer Hill.
Debate about the causes of the Nunney typhoid outbreak continued for over a decade in British medical journals, through the letters pages and articles.
The President of the Society of Medical Officers of Health hailed Ballard’s work in his inaugural presidential address in 1875, saying: “If we consider how, a dozen years ago, those many outbreaks of enteric fever were unintelligible, and how all of them, instead of being merely regarded as unexplained, were liable to be regarded as demonstrating de novo origin of the disease, we shall the better apprehend the caution with which it is necessary still to proceed before we can affirm the adequacy of any common filth-condition to originate enteric fever.”
“Obviously, we have to be incessantly on the look out, not only for these, but for other and even obscurer vehicles for the specific poison; and there are most serious difficulties in arriving at a definite conclusion that no antecedent case has been concerned in the production of a given fever occurrence.”
Ballard was invited to address the annual meeting of the British Medical Association in 1879 about Nunney and other case studies.
Other physicians, however, were sceptical about Ballard’s conclusions. Physician Charles Murchison (1830 – 1879), a noted authority on fevers and diseases of the liver, questioned in A treatise on the continued fevers of Great Britain whether Ballard’s case study indeed showed that an active source of infection was required for major outbreaks to occur. His book became a standard authority on the issue of typhoid and was translated into German and French.
He fought for fifteen years for his opinion that Ballard’s studies in Nunney and elsewhere were not conclusive proof that typhoid could not develop spontaneously, given the right circumstances. He derided Ballard’s idea now accepted by the Privy Council and others that an epidemic always started with a visiting carrier of the disease.
“It is generally admitted that autumnal diarrhoea may result from drinking sewage-polluted water,” he wrote. “But the same polluted water may be drunk for a long time with impunity, so long as it has not been subjected to certain atmospheric conditions common in autumn.”
There was usually a sharp increase in the number of people suffering diarrhoea after hot weather in the autumn.
“It is quite true, then, that excremental poisoning may exist for a long time without any fever. It does not follow, however, that when a sudden outburst of the disease at last takes place, this has always been preceded by the arrival of an infected person,” according to Murchison.