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The crude rates and the standardised rates also indicate that some influence or influences have
been at work fairly steadily throughout the twenty years, reducing in like proportions male and fen ale
mortality. They lend no support to a hypothesis that the fact, that between 1914 and 1918 some four
millions of men were inoculated against typhoid fever, has been a prime factor in reducing mortality.
Dysentery.
To those who accept the view that typhoid fever and dysentery are largely spread by healthy
bacillus carriers, the behaviour of dysentery during and after the war has been even more surprising
perhaps, than that of typhoid fever. True, as the Registrar General states, "the dysentery mortality
in England and Wales was four times as high in 1918 as it was before the war, but 81 per cent, of this
mortality was in lunatic asylums." The rise commenced in 1919, and had reached its height already
in 1917. "It appears, therefore," the report continues, "that although a large amount of infection was
introduced into this country in 1915 and succeeding years, it has shown no tendency whatever, so far
as can be inferred from the death returns, to spread among the general population. The asylum mortality
stands by itself and does not appear from the death returns to have any relation to the health of
the general public." This phenomenon seems to call for careful consideration on the part of those who
hold the belief above referred to.
Dysentery and fever have again and again been associated with war. At the time of the South
African War both dysentery and enteric fever were very prevalent and fatal and a Royal Commission
was appointed to inquire into the "Nature, pathology, causation and prevention of dysentery and its
relationship to enteric fever." The Commissioners, in the introduction to their report of 1903, state
that they visited Johannesburg and Pretoria to ascertain "which would be the most suitable for the estab
lishment of a laboratory, to study the bacteriological and pathological character of dysentery and their
relationship, if any, to enteric fever." The last part of this study is dealt with in Part I. (the bactericlogical
part) of their report, and is not referred to at all in Part II., which relates to field inquiries The
conclusion arrived at is "there is no connection between dysentery and enteric fever. Eteith's bacillus
is not found in the organs or intestines of dysentery." So from first to last the Commissioners make no
reference to the question of any possible epidemiological relationship between dysentery and enteiic
fever; they have, in fact, quite ingenuously limited the scope of their reference, so as to exclude epidemiological
relationship altogether. To such an extent were the minds of medical etiologists obsessed by
bacteriological considerations in 1903. It is scarcely to be wondered at then that they failed in this
part of their quest.
Under the strict limitations they imposed upon themselves, Part I. of their report contains, nevertheless,
points of great interest, for acting under the "instructions given for the guidance of the Dysentery
Commission .. . that the connection between dysentery and enteric, if any such existed, was to be investigated
.. .every favourable opportunity was taken of making post-mortem examination of cases of enteric
and subjecting them to the same procedure as in cases of dysentery ..." and 18 cases of dysentery and
7 of enteric fever thus came under observation.
It is deserving of note that two of the last named were cases of enteric fever followed by dysenteric
symptoms. As regards one of them (case 24) it is said that the case was hard to interpret—it might
be "enteric fever from beginning to end"—"it might be dysentery throughout"—"it might be a case
of dysentery following on enteric fever." On the whole the scale turns in favour of "enteric fever
throughout." The other case (25) is also difficult of interpretation, but again the same conclusion is
reached. The final outcome of the bacteriological inquiry, so far as dysentery is concerned, is that,
"if there is a special micro-organism in dysentery it must be sought for in the large intestine, where, we
imagine, the task of finding it will prove an arduous one."
It is stated at the outset in Part I. that there is "something rather fascinating" in the theory
that "the common colon bacillus may assume a pathogenic role in dysentery," as it was long ago said
to do by French bacteriologists in enteric fever. Whatever prcspect there may be of clearing this question
up, so far as the small intestine is concerned, the above-quoted statement would make it appear that
such a task is likely to "prove an arduous one" when the large intestine comes to be considered. It
will be very interesting to see how in the light of present knowledge these laboratory difficulties aie
dealt with in the enteric fever and dysentery reports, of the Western Front, of Gallipoli and of Mesopotamia.
Meantime, reference may be made to some of the epidemiological aspects of the problems in
question, as revealed in Mott and Durham's report of 1900 on Asylum Dysentery. They, too (p. 27),
considered that it was "advisable to obtain further information about the occurrence of typhoid fever
in the asylums, not only because of the chance of comparison of a better-known specific infective disease,