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21
Report of the County Medical Officer—General.
There were furthermore 5 cases (in which information was given) which proved not to be typhoid.
There were 30 cases occurring in barracks and camps, a dozen or more cases occurring among Belgian
refugees, two cases attributed to bathing in the Thames, five cases occurring among nurses and attributed
to the fact that they had been associated with sulierers from typhoid fever, and one case was that of an
assistant in e bacteriological laboratory.
In addition to the prevalence to which attention was directed by Dr. Sandilands, three other
special prevalences are mentioned in Annual Reports of borough medical officers. Dr. Allan (Westminster)
mentions that twelve refugees from Antwerp who came over in one party, developed typhoid
fever soon after arrival. Examination was made of a number of others in the refuge with a view to
detecting other or carrier cases, but it proved negative. Dr. Davies reports the occurrence in Woolwich
of a group of 17 cases during December, 1914, and January, 1915. This group was "connected
with one dairy," that is to say, if the cases be divided into "primary" and "secondary," the primary
cases belonging to 12 affected houses involved consumers of milk obtained from a particular source.
It would be interesting to know whether there remained any degree of possibility or probability that
this was a mere chance occurrence. In the case of three of the affected houses, the milk was said to
be always boiled, but it is not stated whether the "secondary" cases involved consumers of the milk
or not. The age distribution was not that usually observed in milk outbreaks, and there was marked
irregularity in the grouping of cases around the suspected dairy. Evidence is quoted to show that the milk
could not have been infected prior to its reaching Woolwich, so further investigation of the matter was
limited to bacteriological inquiry as to the existence of a possible "carrier" there. This inquiry was
of a very detailed character and resulted in the "discovery" of a lad who had been employed at the dairy
from whom one of the strains of paratyphoid bacilli was isolated. Dr. Davies reports, however, that
" the blood sera of several patients, though giving a positive Widal reaction, did not agglutinate the
paratyphoid bacilli found in the boy." The investigation was therefore "inconclusive." "No history
of illness could be obtained with regard to this boy." It is further added that Gaertner's bacillus was
found in the faeces of a servant at the dairy and the fseces and urine of a porter who had been observed
to dip a mug into one of the churns at the railway station and help himself to a pint of milk, were
examined, it is stated, with a negative result. Dr. Davies adds that the symptoms observed in the
sufferers were " characteristic of enteric fever of a moderately severe type, and of the cases examined
8 gave a positive Widal reaction and in only one case was there reason to suspect the accuracy of the
diagnosis." Dr. Porter (Marylebone) reports that ten cases occurred in five houses situated within a short
distance of one another ; in six of the cases the onset of illness was between the 8th and the 16th of
April; three of the remainder were developed after an interval of a few weeks, and in the last case the
illness began in July. Dr. Porter states that "when the first three cases came to hand, the conclusion
arrived at as to the source of infection was that A. J. P. (the first case) had probably contracted the
disease as a result of eating contaminated food, the two most likely articles being shell-fish or fish bought
ready cooked."
The varying ascription of suspicion to one and another suspected source depends, of course, very
much upon the personal equation of the observer who makes the inquiry ; it is only possible to draw
conclusions having any considerable degree of probability when groups of cases occur, and when it is
therefore possible to test the extent of association of the ascribed cause with the cases of the disease,
and to compare the extent of this association with that exhibited in a control group of cases. Again,
in the outbreak in the early weeks of 1914 the hypotheses of the rat poison, and of the existence of a
carrier case in the kitchen of the establishment, were rendered extremely improbable by reason of the
fact that simultaneously with the occurrence of the 10 cases, 60 or 70 other cases, which could have
had no association either with the rat poison or with a hypothetical case in the kitchen, were developed
as part and parcel of a widespread excessive prevalence throughout London. The facts with regard
to this outbreak regarded as a whole are, indeed, exceedingly difficult if not impossible of explanation
unless it be inferred that a particular consignment of infected food was at fault, and study which has
been made in previous years, in London, of the distribution of the various kinds of food which have
from time to time come under question, especially attaches suspicion in the present instance to fish.
Just as the making of a comprehensive survey of the cases of a year tends to throw doubt upon
the correctness of the aetiology assigned as the result of examinations of the individual cases making
up the total number, so a comprehensive survey of the various aetiological hypotheses which have
found favour in the course of the last half century tends to cast doubt upon some of the theories which
have held the field, at one and another time, during this period. Thus in the sixties, seventies
and eighties inquiry was always made in cases of typhoid with regard to exposure to effluvia from
excreta, and very great significance was attached to the inhalation of drain and sewer emanations ;
explosive outbreaks were in the latter part of this period generally attributed to water, and towards
the end of the thirty years in question the water origin of cases of typhoid began to assume very great
prominence, any suspicious circumstance with regard to a well was confidently appealed to, and, in
the case of public water services, in-suction, intermittency of supply, and so on, were held to be points
to be specially investigated ; the first milk outbreak was reported upon by Dr. Michael Taylor in 1857,
but it was not until towards the end of the century that shell-fish, fish and various other articles of
food fell under suspicion. The discovery of the Eberth Gaffky bacillus in 1882 had meantime,however,
introduced very considerable complications—on the one hand, bacilli presenting characters, regarded
as those of the specific bacilli, were not as a rule discoverable in the water, milk, shell fish, etc., which
were apparently incriminated in particular outbreaks ; on the other hand, as bacteriologists grew more
and more insistent that the bacillus was the fons et origo tnali, it became increasingly realised by them
that bacteriological theory must be squared with field practice, and the attempt was made to escape