View report page

36
Annual Report of the London County Council, 1912.
markedly from that held prior to 9 or 10 years ago, and it is very elaborately illustrated in a volume of
more than 600 pages. Robert Koch was led to believe that typhoid fever was due to an organism the
natural habitat of which was the human body; indeed, he held that, as one of his followers expresses
it in the present report, this species of organism must necessarily become extinct provided only the
possibility of its growth in that body be removed. Acting upon this belief, the school of Koch, in 1903,
set about exterminating typhoid fever root and branch in South West Germany; the design being not
merely to isolate the sick, but over and above this to search for all persons harbouring the specific
bacilli, and to disinfect or destroy all the infective material produced by these so-called healthy carriers.
This plan was carried out by establishing 11 bacteriological stations for the purpose of examining the
blood and excreta of suspected persons, and upwards of a quarter of a million examinations have
been made. The individuals supplying material which gave positive results have been kept under
close watch, and subjected to severe restrictions, until such time as they were declared on bacteriological
evidence to be free from suspicion. The report shows the remarkable perseverance with which
this scheme has been put into execution, and it details some of the difficulties encountered, more
especially in connection with obtaining the necessary material for examination. In illustration of the
uncompromising way in which the plan has been followed up, it may be sufficient to refer to the case
(mentioned on page 304 of the report) of a chronic carrier of typhoid bacilli, who was under the
necessity of changing her place of abode three times within a single year, because those dwelling in
the houses she inhabited would not tolerate her presence on account of the smell of the disinfectants
she had been required to use.
The results of the nine years' work lend, the official reporters claim, support to the view that the
campaign has been largely successful, for there has been a distinct decline of typhoid fever in South West
Germany, and this decline, it is noted, has been a more marked one than that recorded in Prussia during
the same period; but there was some slight recrudescence of typhoid in 1910 and 1911, in the area of
the campaign itself, and this increase is admitted to constitute a warning that much still remains to be
done. There are not wanting, moreover, scattered throughout the reports, indications that as a matter
of fact far less has been achieved than it had been anticipated would be accomplished. In the sections
of the volumes which deal with dysentery and paratyphoid fever, almost complete failure is practically
admitted, but then, it is argued (p. 94), typhoid fever itself stands on an entirely different footing, for
man alone constitutes the medium ("Vegetationsort") for development of the bacillus typhosus,
whereas paratyphoid bacilli are widely distributed, not in the human species only, but in other animals
and in the outer world. This consideration is held to explain the fact that there has been an actual
increase of paratyphoid fever coincidently with rigorous practice of campaign methods. Again, the
occurrence of the seasonal peak of typhoid is felt to constitute a difficulty from Koch's point of view.
The writers of the reports find that this peak is more markedly developed when the statistical material is
obtained from rural than from urban areas, and they also find that the cases which contribute to the
heightened autumnal prevalence are not the "secondary" cases, but, in the main, the unexplained
cases; the "contact wave" lags behind that produced by the cases of admittedly unknown origin, and
the fact must, therefore, be admitted that the riddle of typhoid may largely lie in the mysterious circumstances
which give rise to this last-named group. The decision as to whether a case is "explained"
or "unexplained" depends, however, largely, the reporters admit, upon the personal equation of the
observer, but even at the lowest estimate the unexplained cases are half the total number.
There are, moreover, various curious circumstances associated with these "unexplained cases";
there is their tendency to occur in small groups, in connection with which suspicion as to infected food
supplies often arises (p. 184); there is their special development in industrial and mining centres, and
their possible association, even in individual instances in those centres, with imported food supplies.
Particularly noteworthy, moreover, is the comparatively slight incidence of typhoid fever upon the rural
areas, for, at first sight, it might be thought that in them the conditions were specially inimical, means
of water supply and excrement disposal being as a rule extremely faulty, though on the other hand
there are few strangers and the inhabitants prepare their own food. When such sparsely inhabited
areas do become involved, the disease sometimes persists in them, and yet, on the other hand, there is
the fact (p. 25), especially difficult of explanation from the stand-point of Koch, that nearly half the
districts yielding cases of typhoid in some numbers in the course of a year are districts newly involved
during that year.
All these peculiarities are passed in review, and so, also, is the question of incidence upon doctors,
nurses, laundry-maids, etc., which it transpires is smaller than had been anticipated; more than, once too,
there is mention of the inconceivability of any important role in dissemination being played by the fly.
On p. 481 a very weighty piece of caution is given, to the effect that, altogether apart from the particular
source suspected in any given instance, there are other possibilities which should not be allowed to pass
altogether out of mind. In all this it is seen how difficulties, which cannot be brushed aside, present
themselves to the painstaking and methodical observers who write these reports.
Perhaps the most interesting of all the contributions is that of Dr. Demuth, of the Bavarian
Pfalz. This observer again and again insists that the behaviour of the disease in the area he is concerned
with has to no inconsiderable extent been influenced by the general measures of improvement which
were undertaken in the seventies, eighties and nineties of the last century, in obedience to the teaching
of that earlier day. He is able to give a chart, showing typhoid fever prevalence in the Pfalz from
1876 onwards, and he deduces (p. 398) from his figures the conclusion that, already in 1903, typhoid
fever had shown clear evidence of decline, although no special measures, of the kind now deemed
necessary, had at that time been undertaken; he adds, however, that acceleration of this decline dates
from 1904, the year of the newly undertaken preventive measures. All through the reports one cannot
fail to be impressed with the evidence presented to the effect that a large amount of attention has been,