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9
There are further exhibited on the lower part of the chart, records, for Grimsby, London and
Home Counties and Hull, and for certain county areas, which show the relation in successive years
of the extent of autumnal prevalence (broken lines) to that of mean annual prevalence (continuous
black lines). It is interesting to note that the marked decline in the rate since 1911, with close approximation
of the broken and continuous black lines in the four succeeding years, are conspicuous
phenomena in the Grimsby, and in less degree in the Hull curves. If the particular type observable
in the Grimsby curve be taken as a standard for comparison it will be found that the London curve is
intermediate between the curves for Grimsby and for Hull. In the case of Hull and of some neighbouring
towns, the rise in 1911 is conspicuous, but the autumnal flattening is not particularly well
marked in 1913 and 1914. Comparison with curves for other parts of the country shows that the groups
of counties marked 1.4 very closely, and those marked 5.7 rather less closely, conform to the Grimsby
type. The groups of counties marked 8.12 markedly deviate from that type. It is worthy of note
that conformation to the Grimsby type fairly closely follows accessibility, by reason of facility of
railway communication, to Grimsby fish supplies. The conformity of South Wales and Monmouth to
the Grimsby type is not readily explicable, but it may be that the mining areas of Glamorgan and
Monmouth receive at times chance supplies of fish of the kind that has been known to be distributed
in the poorer areas of London. If England and Wales be divided into areas largely supplied, less
largely supplied, and least likely to be supplied from the A3 area, the curves of annual and autumnal
typhoid prevalences in those areas present corresponding approximation to or divergence from
the Grimsby type.
The whole question of variations in the type of the typhoid curves in different parts of the country
merits close study, but three facts are at any rate clear. First, typhoid fever reached a high level in
London in the years when there was a maximum use of the A3 area. Second, a decline followed upon
the gradual disuse of this area. Third, a further decline with smoothing out of the autumnal prevalence
has occurred in the last eight years, save in 1908, 1910 and 1911, when there were small autumnal
outbreaks, traced to small ungutted flat fish.
The facts at any rate justify discouragement as a source of supply to this country of undersized
plaice and dabs from the mouth of the Elbe.
On a review of all the facts as to disuse of suspected sources of supply to this country of shellfish
and of fish, it will be apparent that the great decline of recent years in prevalence of typhoid fever
has proceeded practically pari passu with abandonment of consumption of shell.fish and fish from polluted
sources, and, with removal of layings, etc., to a distance from sewer outfalls. In particular it
should be noted that the classical reports of Dr. H. T. Bulstrode, and the adoption of the precautionary
measures outlined in them, must be regarded as having been very largely responsible for the great
reduction in the prevalence of and mortality from typhoid fever brought about in the last 20 years.
Just at the time, however, when the carrying into effect of epidemiological teaching was beginning to
exert appreciable influence, a new bacteriological method of prevention of typhoid fever was first advocated.
This new method has been but little practiced in civil life, save by the campaigners of South.West
Germany, but it has been somewhat widely employed in the British, German, and French armies. It
has been assumed not only that this method has been productive of great results from a preventive
point of view in the case of those armies, but the corollary is apparently drawn that if it had been adopted
twenty years ago among civilians in this country there would have followed not merely the huge decline
in typhoid that has actually occurred, but an even greater decline. To the epidemiologist this is very
hard of acceptance; he inclines to think that more benefit, as regards further reduction of typhoid
fever in this country, is likely to result from pursuing the older epidemiological methods than from
giving effect to the new principles advocated by Koch and his followers. In particular, further care
for the purity of shell.fish layings and entire prohibition of the sale of ungutted flat fish are to be looked
upon as the main lines upon which further advance can be made.
At the close of the year, the Port of London Sanitary Authority made an order prohibiting
the selling of shell.fish from the whole of the area between Canvey Island and Shoeburyness, unless
in the case of oysters they had been relaid for a month in other waters; or in the case of cockles,
mussels, and winkles, unless they had been boiled before being despatched to market.
Diarrhœa
and enteritis.
Deaths from diarrhœa and enteritis during 1916 numbered 2,009 as compared with 3,098 in
1915 and 3,624 in 1914. Of the total deaths, 1,380 occurred during the first year of life and 228 in the
second year, the corresponding figures for 1915 being 2,126 and 430 respectively. Zymotic enteritis
was notifiable throughout the year in Woolwich and during the summer months in Poplar and
Greenwich.
Puerperal
fever.
The deaths in London during 1916 attributed to puerperal fever, numbered 158, as compared
with 132 in 1915 and 195 in 1914. There were 277 cases of puerperal fever notified in 1916 (52 weeks),
the figures for 1915 and 1914 being 276 and 393 respectively. (See p. 17.)
Phthisis.
The civilian deaths from phthisis in 1916 numbered 6,491 as compared with 6,875 in 1915, and 6,476
in 1914. The increased deaths in 1915 were attributable mainly to adverse climatic conditions in the
winter of that year, and these are reflected also in the increased deaths from bronchitis, pneumonia and
influenza. In England and Wales the deaths in 1915 numbered 23,630 males, including deaths in the
forces, and 18,046 females, as compared with 21,412 and 16,414 in 1914; the increase was therefore
slightly greater among males than females. The corresponding figures for London are not
available.
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