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25
Report of the County Medical Officer—General.
by the war, afforded reason for especially closely watching the behaviour of typhoid fever. During
the first quarter of the year 1914, 224 cases, just about the 5 years' average (230) were notified; in the
second quarter there were 153 cases,the 5 years' average being 152; in the third quarter there were only
193 cases, the 5 years' average being 291; and in the fourth quarter there were only 219 cases, the 5 years'
average being 288. In the first quarter of 1915 the number of cases was only 179, considerably less than
that in the corresponding quarter of 1914 and indeed in two weeks, that ending April 3rd and that ending
May 15th, the total number of cases notified in London fell as low as 5. It is specially noteworthy that
in 1914, as in the two preceding years and as also in 1909, there was practically an entire absence of the
autumnal rise.
While the low rate of incidence of typhoid fever in London must be regarded with satisfaction,
it should be pointed out that to some small extent at any rate it is probably due to alterations of nomenclature.
From the first separate record of typhoid fever deaths down to 1884 there was a fairly steady
maintenance of the mortality level; then came a sudden drop to a lower level and the mortality remained
again fairly steady at this point until 1900; since that year there has been a further marked decline.
It is noteworthy, however, that during the past 14 years, in which deaths from appendicitis have been
separately returned, the number of certificates annually dealt with has undergone steady increase,
and at the present time the deaths from appendicitis are about three times as numerous as those from
typhoid fever. Again the cases of typhoid fever notified each year include a large percentage of illnesses
which are not really examples of this disease. The Metropolitan Asylums Board's Annual Reports
give the percentage of cases admitted to the Board's hospitals in which an error in diagnosis was found
to have been made ; this percentage has never been lower than the limits reached in two years of special
prevalence 1899 and 1900, 17 and 18 per cent, respectively; it rises much higher in some years, particularly
in those of low prevalence, and indeed during 1909, 1912 and 1913, recent years of specially low
prevalence, the percentages were 37.9, 40.5 and 40.4. There can be no question that the extended use
of the Widal test (discovered in 1896) has materially influenced the diagnosis finally decided upon in
suspected cases of typhoid fever, and on the whole, during the decade 1905-1914 in which this test has
been extensively used, the percentage of cases deemed to be instances of "errors in diagnosis" has
only three times been less than 30 per cent., whereas in the preceding 15 years 1890-1904 the percentage
only exceeded 30 per cent, on three occasions. There can be no doubt, therefore, that there
has been considerable alteration of fashion as regards nomenclature in the case of typhoid-like diseases
and, indeed, if due allowance be made for this fact, the estimate as to the extent of the decline credited
to typhoid fever in London in the last 15 years must be somewhat modified.
Diarrhea and Enteritis.
The deaths at all ages from diarrhoea and enteritis in the administrative County of London during
1914 (52 weeks) numbered 3,573 as compared with 3,598 in 1913 (53 weeks) Of the total 3,573
deaths, 2,583 occurred during the first year of life and 448 in the second year. In the four quarters the
deaths numbered 354, 329, 2,172, and 718 respectively.
In diagram (U) the death-rate from diarrhoea and enteritis among infants under two years of
age in each year since 1861 is shown in relation to the mean death-rate for the period 1862-1914.

Diarrhoea
deaths in
London
boroughs.
It will be seen from the foregoing table that the death-rate in 1914 from diarrhoea and enteritis
per 1,000 births was highest in Bethnal Green (45.96) and lowest in the City of London (5.52). The
death-rates in London in each of the four quarters of the year 1914 were as follows; first quarter, 9.5;
second quarter, 8.2; third quarter, 70.3; and fourth quarter, 22.7.
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