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eaten shortly antecedent to attack, Dr. Davies mentions the following cases occurring in Woolwich:
" A fishmonger supplied two of the cases attributed to fried fish; he had recently had enteric fever;
two persons outside the borough who bought fried fish from him had enteric about the same time."
Infection from person to person is frequently mentioned in the annual reports as the cause of the
disease. Dr. Warry gives the particulars of five groups of such cases occurring in Hackney, and adds
that in the case of all of these groups the more usual sources of infection could be excluded. Dr. Millson
had reason for thinking some 20 per cent. of the cases in Southwark could be thus explained. There
is no reason for doubting that such infection frequently occurs, especially in houses occupied by poor
persons, where the accommodation is limited and where conditions of cleanliness are not maintained.
A suggestion of exceptional behaviour of the disease in this respect needs, however, close examination.
The annual report of Dr. R. Dudfield gives account of a small outbreak of enteric fever in connection
with the Paddington Green Children's Hospital, which, as he says, will be of interest in connection
with the question of spread of the disease by personal contact. On the hypothesis which Dr. Dudfield
constructs, he finds explanation for the infection directly or indirectly by a particular patient, A. F.,
of at least 25 persons, as follows:—
(i) In the Willesden district there were reported to the Medical Officer of Health, Dr. Butler,
9 cases, to which, says Dr. Dudfield, "a suspicion of connection with A. F. more or less intimate
attached." Here were, in addition, four other persons intimately associated with A. F., whose serum
was found to give a Widal reaction. These four persons had not been ill.
(ii) In the surgical ward, at the Paddington Green Children's Hospital, during September
and early October, a probationer nurse and four patients were attacked. Here A. F. had from August
21st to September 1st been in bed No. 6; two of the patients occupied adjacent beds,Nos. 7 and 5;
another patient occupied a bed, No. 8, next but one to that of A. F., and the probationer nurse
who was attacked was in charge of the side of the ward on which the beds of these patients were placed.
The remaining patient M.S. cannot be assumed to have been infected by A. F. in this ward ; for M. S.
was at the Convalescent Home, at Slough, from July 30th until September 25th. This patient was
brought into contact with A. F., however, at the Convalescent Home.
(iii) At the Convalescent Home 8 cases, or including the patient last named, nine cases, occurred.
(iv) Finally two cases occurred among patients discharged from the Hospital.
Dr. Dudfield found that the child A. F., sot 3, had the following history:—
Until July 31st, 1906, she was living with her mother and brother in Canning Town. The said
mother "is reported to have been fond of shellfish and frequently bought fried fish for supper," and in
June she suffered from an acute illness, which proved fatal on June 20th. A considerable outbreak of
enteric fever had occurred in West Ham (of which district Canning Town forms' part). Dr. Sanders,
Medical Officer of Health of West Ham, informed Dr. Dudfield that the whole history of Mrs. F.'s case
was highly suggestive of the view "that the pneumonia and heart failure (the certified causes of death)
from which she died were complications of an ambulatory form of enteric fever." On July 31st A. F.
and her brother S. F. were brought to St. Vincent's Home, Paddington, and were on the same day handed
over to Mrs. B., foster mother, living in Willesden. A. F. was "ailing" during the two or three weeks
she lived in Willesden, and on August 14th and 21st was taken to the out-patients' department of the
Paddington Green Children's Hospital; on the latter date A. F. was admitted as an in-patient suffering
from pneumonia.
Between August 21st and September 1st A. F. was in the surgical ward of the Paddington
Green Children's Hospital.
From September 1st to 5th A. F. was in the medical ward of the above hospital.
From September 5th to 20th A. F. was at the Convalescent Home at Slough.
On September 20th she was "readmitted," (apparently) to the Paddington Green
Children's Hospital.
Dr. Dudfield, on reviewing A. F.'s history, writes: "This information tended to confirm the suspicion
that A. F.'s case was really one of enteric fever, a suspicion which was converted to a certainty
by the Widal test on October 5th." Dr. Dudfield concludes that the child A. F. was originally infected
in Canning Town in June, and "was capable of spreading infection from July 31st or thereabouts until
October 2nd, when full precautions were put into operation."
Even on the assumption that the Widal test is final, and that A. F. was on October 5th convalescent
from enteric fever, it by no means follows that she was capable of spreading infection from July
31st onwards to October 2nd. Thus, taking first the Willesden group of cases, it will be found that the
evidence here is of an ambiguous character. Dr. Butler discusses, in his third quarterly report for
1906, the possible influence of the polluted water of a canal "feeder" in causing the outbreak in his
district. Furthermore, Dr. Dudfield refers to the fact that one of the Willesden patients was
employed at the Kensington disinfection station and had there "handled bedding, etc., infected with
enteric fever." Again, while Dr. Dudfield, in alluding to the Willesden cases, speaks of "more or less
intimate" connection with A. F., Dr. Butler writes, with regard to three of the cases (occurring in
two houses), "it must be admitted that no communication (between them and A. F.) can be
traced."
On turning, however, to the second group of cases, those occurring in the Paddington Green
Hospital, the facts recorded are strongly suggestive of personal infection, though here again it is by
no means certain that A. F. was at fault; there is, indeed, of course, a possibility that she was herself
infected in the hospital and not the original source of introduction of infection into that institution;
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