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A chart was exhibited which showed that the 50-year decline was the result in the main of the great
sanitary campaign of the last half of the nineteenth century, and especially of the attention devoted to
obtaining pure water services throughout the country ; while the continued and accelerated fall of the
last twenty years appeared attributable partly to the cumulative effect of the advances thus made, but
largely also to the cutting off of certain grossly polluted shellfish and fish supplies. The view has been
consistently maintained in these reports, for the last ten years and more, that (in London at any rate)
typhoid carriers, flies, milk, ice-cream, and watercress have not been responsible for the spread of typhoid
fever. Furthermore, that the part played by direct case-to-case infection cannot be in any case an
important one; while the influence of preventive inoculation has been altogether negligible. With
these considerations in mind it was possible, in 1914, to reach the conclusion that the effect of the war
was not likely to be to increase, as some supposed, the risk of spread of the disease, but to diminish it.
This expectation has been realised. Moreover, as an outcome of the experience gained in the last seven
years, the vogue of the carrier hypothesis has materially lessened ; the conviction having steadily
gained ground that typhoid fever is for the most part water-borne and food-borne ; there remains
still, however, in many minds the belief that case-to-case infection is quite commonly met with, and
that important influence so far as males are concerned has been exerted in the last few years by protective
inoculation. London experience does not lend support to either of these hypotheses (see p. 25).
There emerges, however, from further study of the remarkable reduction in typhoid in the civilian
population, right down to and persisting through the war period, and after, reason for directing attention .
to the possibility that some small influence has been exerted in this connection by altered nomenclature
now arising from the special reliance placed upon bacteriological as distinguished from clinical tests
for purposes of diagnosis. The transference of cases, which in former years would have been classed as
typhoid, to other categories, such as dysentery, diarrhoea, appendicitis, not to mention influenza, trench
fever, and " pyrexia of unknown origin," is a factor to be reckoned with in considering the decline of
typhoid fever. In particular as the outcome of recent experience, the question as to possible confusion
between typhoid and dysentery is one to which attention may be especially directed, and on this subject
some comments are made on p. 28.
As regards tuberculosis, the war and the aftermath of the war have resulted in clear demonstration
of the fact that lowering of resistance (resulting from poor feeding, for example) is a far more important
influence for harm than increased exposure to infection. This subject was touched upon in last year's
report, and is here again noticed. "The Influence of Migration upon the Phthisis Death Rate"' was
first brought under notice in 1912, Two striking phenomena doubtless related to this influence have
become clearly apparent since the commencement of the great war, and are referred to on pp. 13-14.
Reference is made, moreover, in view more especially of its important bearing upon the influence of
migration upon the death rate from phthisis, to a paper which appeared in 1920 on The Mortality of
Race Stocks in America (p. 17). An important report on tuberculosis by Dr. Greenwood, which
appeared in the Annual Report of the Chief Medical Officer of the Ministry of Health for 1919-20, is
also commented upon, attention being especially directed (in Part I. of the present report) to the
questions raised by Dr. Greenwood concerning the influence of migration and industrialisation, and (in
Part II.) to the influence of immunisation in early life against subsequent attack.
As for the influenzal group of diseases, so far as their prevalence in 1920 is concerned, there is
fortunately but little to record. Cerebro-spinal fever, poliomyelitis and polioencephalitis and encephalitis
lethargica are referred to on pp. 19-23. Epidemic hiccough, though observed in a few cases in London, has
been less conspicuous than on the Continent. This affection and encephalitis lethargica are generally
regarded as closely associated with influenza. As they have no bacteriology, the bacteriologist
abandons them to the wolves without regret. The question of sore throat and glandular fever, which
prevailed in London in the autumn, and which may have been also influenzal in origin, is referred to
in Part II., p. 89. Some of the lessons to be learnt from the behaviour of influenza in the recent
outbreaks are considered on p. 18.
During 1919 there was a great coming and going of refugees and soldiers through London, and
at the middle of that year it was calculated that there was a net addition of 400,000 to the London
population. In 1920 this special traffic of 1919 came in large measure to an end, but there was beginning
to spring up a new movement of emigrants proceeding westwards and ever increasingly passing on their
way through London from Europe to America. These movements of population necessitated close
attention being given to the question of risk of spread of epidemic disease.
tions. The Council's tuberculosis scheme of May, 1914, was further extended in 1920, and there was,
moreover, in contemplation during that year the addition to the Council's responsibilities of charge
of the institutional treatment of insured as well as of uninsured persons. The scheme for London and
the Home Counties, for the diagnosis and treatment of venereal diseases, inaugurated on 1st January,
1917, was also extended, and a comprehensive survey was made of the available provision by Brevet
Lt.-Col. Harrison and Dr. F. N. K. Menzies, the results of which are fully set out by Dr. Menzies in the
Appendix to this Report.
Much additional work was thrown upon the Public Health Department arising both out of official
representations with regard to unhealthy areas in London (see p. 33), and in connection with the Building
Control Act. The framing of new by-laws (which the Council is empowered to make) under the Housing
and Public Health Acts has also been under consideration. Reference will be found in the Report to
work carried out under Part I. of the Children Act, 1908 (p. 45), under the Midwives Act (p. 40), and
the Mental Deficiency Act (p. 39). An account of methods used in connection with examination of
children under the last-named Act, by Dr. F. C. Shrubsall, is given in Part II. of this Report (p. 95).
The work of the Chemical branch of the Department and the experimental work in connection with the
biological treatment of sewage now inaugurated at the sewage outfalls, are referred to on pp. 46-47.