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20
Annual Report of the London County Council, 1914.
At the beginning of the year 1914 there was a heightened prevalence of typhoid fever in London.
When the cases are arranged according to the week in which the onset of symptoms occurred, and the
number of cases developing in each week are set out in the form of a chart, a marked increase is first
noticeable in the week ended 27th December, 1913, and this increased prevalence continues for some
9 weeks, during which period 161 persons developed the disease. This is about double the number that
might have been expected, having regard to the normal behaviour of typhoid fever at this time of the
year, and it is, therefore, probable that some 70 or 80 of the cases occurring in London during the last
fortnight of 1913 and the first six or eight weeks of 1914, were due to the operation of a special
cause.
Typhoid
fever prevalence
in
1914.
My attention was called soon after the development of the outbreak, by Dr. Sandilands, to the fact
that several persons working at a particular establishment in Kensington had been attacked by typhoid;
Dr. Menzies on behalf of the County Council conferred with Dr. Sandilands, and effort was made to
discover the cause of this special incidence of typhoid upon the employees in question. In all ten persons
associated in one way or another with the particular establishment were found to have been attacked;
the total number of workers was large, but the cases of illness were far in excess of those which would have
been expected in a population of the size in question as a matter of mere chance. Various possible
sources of infection were enquired into ; the cases commenced, one in the 3rd, one in the 4th, two in the
5th, three in the 6th, two in the 7th, and one in the 9th of the nine weeks above referred to. There
were certain facts strongly suggestive of a food origin of the outbreak ; thus one of the patients was
steward of a club situated many miles away from the establishment in question ; employees at the establishment
went to this club, and some of the sufferers were known to have partaken of food there ; on
the other hand the steward sometimes came to the establishment in question ; again, the dining arrangements
at the establishment itself involved differentiation of the employees into certain groups, and
this fact led to suspicion being especially directed to particular groups, and ultimately to inquiry into
the kitchen arrangements generally. As to the way in which, if it were at fault, the food supply became
infected, no certain conclusion could be reached, though detailed inquiries were prosecuted in many
directions, including investigation of cases of previous illness among workers in the kitchen and
bacteriological enquiries concerning a rat poison which was said to have been used on the premises.
The outstanding fact elicited, as the result of the fullest enquiry into the history of past illness
among employees, was that the number of cases among workers at the establishment only amounted in
all to ten, or about 12 per cent, of the excessive number of cases occurring in London as a whole, during
the weeks in which the exceptional incidence of the disease was manifested. This fact makes it highly
probable that, if food was at fault in the case of the ten persons , it was at fault too in the case of all
those who must be regarded as included in the special prevalence of the disease.
Such enquiry as had been made with regard to the cases in London generally had shown their
wide distribution over the county, though, as reference to the accompanying map, Diagram (T), will
demonstrate, there were certain noteworthy groupings of the patients commencing to be ill during the
particular nine weeks in question—thus, a group of cases in Fulham and the adjoining boroughs includes
most of the 10 cases among employees at the special "establishment"; but in addition there are well
marked Wandsworth, Lewisham, North and South Islington, and North West St. Pancras groups; in
two at least of these groups (not including the "establishment" group), suspicion strongly attaches
to food supplies as the source of origin of the mischief; further, it may be noted that the age-incidence
of the cases was not specially remarkable; and speaking generally of cases occurring during the 9 weeks
it transpired that in a considerable number of instances the fact that fried fish or shell fish (mussels,
oysters or winkles) had come under suspicion was recorded. It was not possible to carry the matter,
further, but on the whole the evidence points to the probability that either fish or shell fish was at fault.
Attention may especially be directed to the well marked group of about a dozen cases, five in one family,
occurring in Lewisham (in instances in which more than one person living in a house was attacked, the
additional cases are indicated by concentric circles surrounding a central dot, see map). The part of
London in which this group occurred is remote from the "establishment" already referred to; one
of the patients was a fishmonger's assistant, and all the patients were associated in one way or another
with the shop in which he worked. In addition, in other parts of London a fishmonger and a fish
stall keeper were among the persons attacked during the weeks of special incidence.
Dr. Menzies continued to make an analysis of the facts to hand as to the cases of typhoid fever
which were notified in London throughout the year, as it was thought possible that the same cause which
had operated in the early weeks of 1914 might again yield evidence of producing mischief. This
expectation was not fulfilled but the returns, which were most courteously made by London Medical
Officers of Health, have been carefully studied by Dr. Menzies, and they show that a particular
source of infection came under suspicion in the following number of instances.