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the particular sample examined. To exclude this possibility a number of samples of dried peas from
the same consignment were examined and the report received from the Ministry of Health laboratory
was as follows :—
Nine samples of dried split peas from various sources (same consignment) sent by the
Medical Officer of Health, St. Pancras.
No organisms of dysentery or enteric group found. B. Coli, non-lactose fermenting coliform
bacilli (B. fiscal is alkaligenes type) and B. proteus present in over 50 per cent. of the samples.
B. Welchii, aerobic sporing bacilli (B. subtilis type), non-hæmolytic streptococci and
staphylococci present in 100 per cent. of the samples.
Seven samples of dried split peas belonging to the same consignment, received from Medical
Officers of Health, and one sample bought locally over the counter. All gave growth of similar
types of organism.
This report appeared definitely to exclude the dried peas as the source of infection and to
confirm the suspicion that the pudding was infected after having been made.
The fact that the consignment of dried peas in question (which had been imported from Poland
and milled in Holland) consisted of a thousand 1 cwt. bags, that 700 bags had been distributed
throughout London and the country, and a large quantity of the peas consumed, without ill effect,
was also an important factor in excluding the peas from suspicion.
The staff at the shop, which was a lock-up shop, was stated to consist of the proprietor and his
wife. Samples of their blood, urine and fieces were examined, but were found to be negative. This
excluded the above persons as "carriers."
No rats or mice had been noticed on the premises, and although these animals may be carriers
of pathogenic organisms of the Aertrycke-Gærtner group, they are not known to carry dysentery
organisms.
As a result of further inquiries, it was ascertained that a little girl, age nine years, and two
adults, although residing elsewhere, occasionally came to the premises, and sat, either in the shop
or in the room behind the shop. Samples of their blood, urine, and feces were examined. The
results as regards the two women were negative, but the child's faeces contained large numbers of
dysentery bacilli of the Sonne type, and her blood re-acted in a dilution of 1-125.
It is unfortunate that nine days had elapsed before the above information was obtained, and the
blood, etc., examinations were made, as it was now discovered that the child had been in the room
behind the shop in which the pease pudding was kept on Saturday, the 7th October, between 7.30
and 8 p.m., and on being questioned admitted having eaten some of the pease pudding, taking it out
of the vessel with her fingers.
The point that now arose for consideration was whether the child was the cause or a victim of
the outbreak. If the blood examination could have been made at an earlier date this problem would
not have arisen.
In the opinion of the bacteriologist, it was unlikely that the blood would have re-acted so
strongly if the child had only been infected nine days before. It is also important to note that after
eating some of the pudding on Saturday evening no symptoms of illness followed. The child was
quite well on Saturday night, the whole of Sunday and on Monday until about 4.30 p.m., when she
came home complaining of some abdominal pain and a feeling of sickness. She had a holiday from
school on Monday and went to Hyde Park for the day with the maid. For her mid-day meal she had
some fried fish with much vinegar, then had some ice-cream, and previously had eaten a banana.
This very injudicious combination was doubtless responsible for the abdominal discomfort, as a
dose of castor oil promptly effected a cure.
In outbreaks of food poisoning it is notoriously difficult to trace the exact source of infection,
and in a large percentage of cases this is not ascertained. In the present instance, on reviewing all
the evidence, it would appear to have been definitely established that:—
(1) The child was a "carrier" of dysentery organisms.
(2) She infected the pudding on Saturday, the 7th October, when taking a portion out of the
receptacle with her fingers.
(3) This act was responsible for the outbreak.