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with very slight power of spread from person to person, but also because of the occasional confusion
in diagnosis between dysentery and this fever, as was met with for instance by Turner." They sought to
obtain returns, and note that "it is strange that in five large asylums, each with roughly similar numbers
of patients, no single case of enteric fever should have occurred in the space of three years, whilst at
the other three, where the conditions and class of persons are to all intents similar, so many cases should
have occurred." Their attention was turned, as has been that of other observers before and since, to cases
in laundry workers (p. 29), and in workers amongst sewage-polluted soil on irrigated areas (p. 32), to
the involvement of particular wards (p. 36), to the implication also of attendants and officers (p. 38);
and they note (p. 40), that all the attendants attacked "lived in," and that bedridden patients, as
well as those who ar£ up and about, suffer.
Close study of ail these points has been made by Drs. Brincker and Wanklyn, in consultation
with the mental hospital superintendents, in connection with the London prevalences of the last few
years; recommendations have been drawn up with a view to preventing spread of infection through
laundry operations, and the subject of food, including fish supplies (shell-fish can be practically excluded)
has been explored. In each of these directions no final results, one way or another have, however,
baen reached.
On the one hand it must be agreed that the facts elicited from the institution inquiries relating
to "dysentery," if not to "typhoid" also, accord more easily and naturally with case-to-case infection
than do those elicited from study of extra-institution typhoid. But, on the other hand, food cannot be
absolutely ruled out. True it is difficult to explain, on a food hypothesis, how it comes about that one
institution is taken, or one side of an institution is taken, and another left. But at this point the facts
elicited with regard to typhoid may be recalled—the limitation of outbreaks in London in the last
20 years to persons consuming certain kinds of fish and shellfif-h. Its excessive incidence in particular
years—for example, in 1911 (see diagram, p. 17, Ann. Rep. for 1919) upon populations supplied with
East Coast fish. In this connection, too, it may be noted that while typhoid moitality is highest in Ihe
Northern Counties, "the Midlands" (to quote the Reg. Gen'. Rep. for 1918) "and not, as is usually
found, the South, hold the best position." The comparative freedom from attack of inland populations
(Bir ningham, for example) during the war years, moreover, has been specially noteworthy. Another
fact noted by the Registrar General is the "great advantage of county boroughs over the smaller towns
and rural districts, a feature of recent development." The county-boroughs may, perhaps, be thought
of as being, prior to the war, owing to smaller freight charges, exposed to n ore risk of receiving polluted
fish supplies than sma'ler towns and rural districts; just as London wrs undoubtedly more exposed
to such risks than, say, Birmingham. These risks were, however, as has been elsewhere explained,
materially reduced on the outbreak of hostilities.
Again, the behaviour ot typhoid in large American cities during the last 15 years is very interesting
in a somewhat similar connection. The improvement of water supplies in America came nearly 20 years
later than the improvement here; our improvement was fairly continuous down to 1885, after which
date there was almost complete arrest until 1900 (Rep. of Reg. Genl. 1919). It is not until within the last
15 years that the death rates in large American cities have come to rival our rates of 15 or 20 years ago.
As the water peril has diminished, at first here and later in America, it has become clear that a residual
peril (certainly from shellfish, possibly from fish also) still remains, and it is interesting to obseive that
some of the inland cities in the New World (Chicago, Milwaukee, Minneapolis, St. Louis, St. Paul, for
example) take pride of place now, corresponding to that of the Midlands in this country as noted bv the
Registrar General.
It appears from figures given in a table on p. 862 (Journal of the American Medical Association,
25th March, 1921) that there are 24 large American cities with a death rate from typhoid not exceeding
3 par 100,000 in 1920, and of these only two (Boston and New York) are on the Eastern seaboard On
theother hand there are 41 cities with a higher death rate, of which 11 are actually on the Eastern seaboard,
and some 12 others ar3 within a few hundred miles thereof. It must, of course, be remembered that
there is a noteworthy concentration of population in the north-eastern section of the United States area ;
but despite this fact it must be regarded as a striking feature of the tab'e that so many cities with high
rates should be located east. The review in the American Journal makes mention, apart from water,
to which special significance is, of course, attached, of milk, flies, carriers, and protective inoculation,
but does not allude to shellfish. This is remarkable since a good deal of work upon shellfish typhoid
comes from the U.S.A. New Haven, Connecticut (a city which it is observed has still a rate of 6.1 per
100,000) was associated with one of the earliest outbreaks of typhoid traced (by Professor Conn) to the
consumption of oysters.
The outstanding impression left on the mind after examination of the behaviour of enteric fever
and dysentery in the London mental hospitals is that it would be well in the future if further attention
were devoted to study of "the relationship, if any" between the two diseases. As a beginning, the
accompanying chart has been prepared to illustrate the way in which they have prevailed in association
with one another, in the institutions concerned, throughout the war years—not that they have
always affected an institution, or even the two sides allotted to male and female patients, and certainly
not the same wards in any of the institutions, simultaneously; but that, viewing the institutions as a
whole, there is a suggestion that some as yet not clearly envisaged influence may have been operative
producing the epidemiological phenomena in question.
The annexed diagram shows the mortality ascribed to enteric fever and dysentery respectively
in London as a whole during the last seven years, and the cases among inmates of seven institutions
(mental hospitals, each accommodating some 2,000 patients) during the same period. The cases of
dysentery represent a substantial proportion of the total number of cases belonging to London.
It will be noted that enteric fever (shown above the line) was lower in London as a whole in 1918-20
than in the earlier years Institution A was almost entirely free from cases. In B and E women only were