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65
In the early stages of the investigation, certain circumstances indicated that another
food might, possibly have been the indirect cause of the outbreak, and it is advisable this
should be mentioned In the week preceding the outbreak, several of the kitchen staff
had been unwell after eating some cold beef This beef was cooked on Sunday, August
26th, and allowed to get cold. It was eaten by the residents on Sunday evening without
any ill effect. The remainder was eaten by several members of the kitchten staff on the
following Tuesday, and on the next day (Wednesday) these persons suffered from diarrhoea,
vomiting, and more or less malaise. The beef was stated to have had a rather unpleasant
taste on the Tuesday, and in consequence one or two of the kitchen staff declined it.
These persons remained in good health. It is conceivable that the beef might have become
contaminated with Gaertner Bacilli, and the infected members of the kitchen staff, acting
as carriers for a few days, could have conveyed the infection by unwashed hands to the
junket. The evidence, however, obtained by the agglutination test is opposed to this view.
Although the blood of one of the maids who was unwell after eating the beef agglutinated
Gaertner Bacilli, this maid had also eaten junket, and sufficient time had elapsed for the
reaction to have, developed from the later infection.
Additional evidence on this point is, however, available. Another member of the staff
who had some of the cold beef on Tuesday, August 28th, and was somewhat indisposed on
the following day, was absent on Thursday, September 6th, and therefore did not partake
of the dinner at which the junket was served. If the beef had been infected with Gaertner
Bacilli, the blood of this person should have possessed agglutination properties, but a sample
was taken and examined and found to be quite negative. In addition to the above, the
statement that the beef had an unpleasant taste would rather indicate it was undergoing
change owing to the presence of putrefactive organisms, as food poisoning germs of the
Gaertner type do not cause any obvious change or unpleasant taste in the food.
I am therefore of the opinion that it was the junket, and not the beef, which by some
means became infected and was the cause of the outbreak.
An occurrence of this kind emphasises the necessity for scrupulous cleanliness in the
handling of food and the importance of keeping it covered in order to avoid the risk of
contamination by rats, mice, flies, etc.
Although it may not be a factor in this instance, I think it. desirable to draw attention
to the fact that some years ago the premises where the outbreak occurred were badly
infested with rats, and a large quantity of "Virus" was used to exterminate these pests.
There are several varieties of "Virus" on the market, but all are stated to consist either
of Gaertner or other closely related organisms. In rats and mice these germs cause an
infectious and fatal disease. The accidental contamination of human food by these germs
is a not infrequent cause of outbreaks of poisoning.
It would therefore appear to be inadvisable to permit the manufacture and indiscriminate
sale of preparations which may become so widely distributed, and which possess such
dangerous properties, when other and safer means of getting rid of vermin are available.
October 4th, 1928.
G. Sowden,
Medical Officer of Health.