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(Journal of the American Medical Association, 26th March, 1921, p. 863). It has been thought well,
therefore, to examine the data furnished by the population of London as a whole (p, 24). The figures
are given in the annexed Table.

At the ages 45 and upwards, in which inoculation scarcely complicates the question at all, it
will be seen that in both sexes there is from 1911 to 1920 a general downward trend, to about half as
many cases in the last three years (1918-20) as in the first three (1911-13). In women 20—45 (again
practically an uninoculated population) a closely similar movement of the figures is discernible.
In the civilian men 20—45, there is observed a greater reduction, first shown in 1915, marked in
1916 and more marked still in 1917; the proportion of civilian men attacked closely corresponds,
however, with that of women, if regard be paid to the fact that by 1917 approximately half the men
were away on military service. In 1918 the position was not materially altered; in 1919 and 1920
most of the men who had not been killed or badly injured returned to ordinary civilian life. In 1920
the cases at ages 20—45 in both men and women rise, those in women are 122 as against 72 in men.
It should be noted that some 20 of the former cases belong to a group of cases of "paratyphoid fever,"
occurring in a women's college in the spring of the year; if this group of cases be excluded from consideration,
the figure 72 for males is approximately the number that might have been expected, having
regard (a) to the general trend of the figures in the other three groups, viz., women 20—45 and men and
women over 45; (b) to the greater number of women at risk at ages 20—45. The excess of women at
20—45 cannot be precisely given, but it was about 16 per cent, above that of men just before the war,
and, if account be taken only of the men "killed in action," the excess must have been about 24 per
Cent. above that of the men in 1920. The 72 cases in men are, it should be understood, civilian cases
and do not include a small number of cases still in military hospitals in 1920. The figures for the London
civilian male population do not, therefore, when comparison is made with uninoculated women of like
ages, or with uninoculated persons of higher ages lend support to the view that inoculation has afforded
any appreciable lasting protection to the men at risk.
The American article already referred to especially emphasises the great importance to be attributed
to improvement of water supplies. The typhoid death rate it is pointed out has fallen to something
like one-tenth of its former rate during the last 15 years. In view of this fact and of the
consideration that inoculation of course can in any case only come into question subsequent to 1916,
it seems strange that, having swallowed the camel of admitting a reduction in the typhoid death rate
of 57 cities from 19 59 per 100,000 in 1910 to 7.61 in 1916, the American article should strain at the gnat
of assuming that a continued reduction from 6.65 in 1917 to 3.52 in 1920 may be regarded as resulting
from the maintained influence of the causes previously at work. (See Table loc. cit., p. 863.)
It is of course admitted that the theoretical interest as to the possibility of inoculation being
also in question is great, but the figures up to date will scarcely bear the burden of sustaining the argument.
As Dr. Greenwood says, "If any bacteriologist thinks that the elimination of, say, epidemic
disease of the typhoid group, can be secured by immunising the population first against B. typhosus, then
against paratyphoid A, paratyphoid B, paratyphoid C, and so on, to the end of the alphabet, all other
things remaining constant, he must be rather naif." Some further addition can now be made to Dr.
Greenwood's alphabetical list of typhoid bacilli, inasmuch as Rosher and Wilson ("Lancet," 1st January,
1921) suggest in the light of their case of typhoid "due to Gartner's bacillus, the advisability of testing
the sera of patients suffering from enteric-like infections against a more extended series of antigens than
are common'y employed."
Further evidence bearing upon the point at issue is furnished by the Registrar-General in his
annual reports for 1918 and 1919. In the former (p. lvi.), after stating that the mortality in the civilian
population ot England and Wales, 26 per million living, was the lowest ever recorded, he adds, "to some
extent this fall is due to absence on foreign service of a large number of males of the ages at which
mortality from this cause is highest; but (after allowing) for this change in the population the standardised
deatli rate of males remains considerably below previous records." And then, following upon this statement,
there comes, in the report for 1919, the announcement of a further decline of mortality from
enteric fever to 16 per million living, and the annexed table is given showing the crude rates
and standardised rates, for males and females, 1901-19. The excess of the standardised rates for males
over the crude rates, which arose in the years before 1919 from absence on foreign service of a large
number of males of the ages at which mortality from this cause is highest, has now almost disappeared.
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