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83
It will be seen, therefore, that there were two main periods of " typhoid fever "
prevalence— the years 1898.1900 and 1917-1918. The former period corresponds with
unusual prevalence of typhoid fever in London generally, the latter period certainly
does not. On the whole, on the balance of probabilities it seems likely that the
prevalences of 1898.1900, like those in London as a whole, were in part due to infected
food (fish); but it is interesting to note the association of the " asylum dysentery "
of those years with typhoid fever, an association not apparent in London generally.
On the other hand in the later years, 1917 and 1918, the majority of the cases of
intestinal disorder in the mental hospitals may have been associated with the
scarcity of food due to the submarine menace of those years ; perhaps the influenzas
of 1918 and 1919 may also have accounted for some of the coincident gastro.intestinal
mischief in mental hospitals. The facts, so far as they are ascertainable
after the lapse of years, have been set out in some detail, as the material available
from these great institutions seems to be particularly deserving of the closest
attention ; the more so as a large amount of pains and trouble have been taken by
those concerned to record the results of their enquiries. This review of the history
of these diseases in the mental hospitals raises questions of very great interest in
connection with study of the epidemiology of both typhoid fever and asylum dysentery
generally.
In the Annual Report for 1919 there is a diagram (p. 14) which shows three
stages in the history of typhoid fever in London. In 1869 the description " typhoid
fever " was first recognised for purposes of tabulation by the Registrar.General, and
from 1869 to 1884 " typhoid fever " declined from 340 deaths per million to less than
half this amount, i.e., to under 150 deaths per milion. Then during the second
period, from 1885.1900, the mortality remained almost stationary; in the third
period, after 1900, the typhoid death.rate again fell, this time to a minimum of less
than 8 deaths per million in 1923. During the first period the death.rate in females
fell much more than that in males, and the death.rates at the extremes of life more
than those in the middle portion. These changes tend to confirm a suspicion that,
in the early days of registration of typhoid fever deaths, much difficulty was experienced
in deciding the precise nature of the disease under consideration. Then with
the arrest in the fall in the death.rate at all ages from 1885.1900—i.e., in the second
period—there seems to have been, so far at any rate as age and sex incidence can be
taken as guides on the question, more uniformity of type in the kind of disease
coming within the designation " typhoid fever." There were, however, among the
cases seen in the M.A.B. hospitals quite a considerable number (20 per cent, to
25 per cent.) found to have been wrongly diagnosed. In the third period there
came a time (about 1909) when the ordinary seasonal (autumnal) prevalence of
typhoid fever flickered away, and since 1912 it has almost disappeared. The percentage
of mistaken diagnoses, represented in the much attenuated lists of notifications
of " typhoid fever," has so far increased, that apart from cases infected from
abroad there have been, speaking merely from the clinical point of view, very few
typical examples of the disease forthcoming. The conclusions to be drawn seem,
therefore, to be
(i.) That in the first 15 years of typhoid fever registration the mortality returns
include a large proportion of deaths not really attributable to typhoid fever. Some
of the deaths returned from certain institutions, even some years after 1884, probably
come within the same category.
(ii.) That from 1885.1900, and in less degree for 9 or 10 years thereafter, typhoid
fever, clinically speaking, so far as the large majority of carefully diagnosed cases
was concerned, fairly well conformed to type; those affected with it in London
throughout the 15 years in question were mainly quite poor persons ; the disease
moreover, exhibited a fairly constant age and sex incidence.