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typhoid trend in other localities on the basis of London experience" is first
deprecated, and, the writer then continues, "An unbiassed observer will be prepared
to accept the view that winkles, oysters and fried ungutted plaice are"—or, rather,
it should read have been in the past—" a relatively common cause of typhoid in
London, but cannot admit that carrier infection, milk-borne infection and similar
factors are entirely inoperative, or even materially less operative than they are
elsewhere." The answer to this friendly criticism is first, that the thought, so far as
America was concerned, was, of course, prompted by study of the Washington
report of 1916, which, it was realised supported the conclusions of Bulstrode's
report of 1896, of his later report of 1911, and of various papers and researches in
this country following thereon; and second, that historical and geographical pathology
is the very life-blood of epidemiology and hence typhoid causation can only be
adequately studied by comparing and contrasting experiences gained at various
times and in different parts of the world.
It is a never to be forgotten fact that, as noted elsewhere (Public Health, 1921,
p. 57), "A President of the Society of Engineers, fifty years ago, was able to trace
all cases of typhoid fever, coming under his notice in London, to faulty drains; the
next succeeding generation concentrated its attention upon contaminated wells;
their successors suspected river water supplies and polluted milk ... in Belfast,
cockles have undoubtedly been paramount; in Germany, the appeal has consistently
been made, since the early years of the present century, to healthy carriers ; in the
armies in the Great War, protective inoculation was deemed to overshadow everything,
and in South Africa, in the Spanish American War and elsewhere, flies have
been regarded as very important"; and now there must certainly be added shellfish
in America, as well as here; while even ice-cream, watercress, and quite lately,
cream-buns and many other articles of food have been thought of as possible vehicles
of infection. Clearly, much is to be learnt, here and now, by study of the behaviour
of typhoid fever in other times and in other parts of the world, and American
experience is far too intriguing for the idea ever to be entertained that workers in
London can afford to refrain from study of "the typhoid trend in other localities,
on the basis of London experience."
The problem presented by "residual typhoid "is, indeed, one of very great
difficulty, and demands most careful examination; for it is obvious that the
preventive measures now advocated by the bacteriologist, owing to the comparatively
recent date of their introduction on any appreciable scale, cannot have caused the
huge decline of typhoid fever observed in the last quarter of a century; it is the more
necessary, therefore, while scrutinising most thoroughly every possible suggested
means of preventing disease, to avoid losing a sense of proportion; it is idle to ignore
moreover the probability that mischiefs, which are known to have operated widely,
in this country, even up to 25 years ago, may still from time to time be found even
nowadays to be potent for harm on occasion.
In London, typhoid fever, from 1912 to 1924 (with small exceptions referred to in
the annual report for 1924), practically ceased to exhibit the once familiar autumnal
increase; it also failed to show the special incidence upon poor populations so
strikingly manifested from the time when the disease was first made notifiable—i.e.,
from 1890, until a few years before the War. The number of notified cases, in which
the diagnosis was not confirmed on removal to hospital, has been in recent years even
larger than heretofore; but a still appreciable percentage (though a small actual
number, of the cases occurring in the last few years, has continued to be attributable
to causes recognised at least 25 years ago as responsible for typhoid fever. The
sex-incidence of the disease, it should be added, at ages 20-45, has notably altered,
and, naturally there has been a tendency to ascribe this to the protective inoculation
(mainly of males) practised during the war ; but, as has been pointed out, the gross
figures as regards sex-incidence, lend no material support to this view. The