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Report of the County Medical Officer—General.
37
and is still being, devoted to nuisance removal, to improved methods of excrement disposal, to bettering
of water supplies, and so forth; in various sections of the reports the millions of marks expended, and
the details of changes effected, etc., etc., are all set out. Again, on page 374, the remark is made that
the greater care exercised during recent years with regard to food supplies may have had influence in
lessening prevalence of typhoid. Speaking generally, however, one fails to detect that the beneficial
effect of these measures has been fully appraised in considering the causes of the decline of the disease.
This remark is not, however, applicable in the case of Dr. Demuth. In his report he alludes to
the ground water theory of Pettenkofer, and recalls the belief entertained 40 years ago, in the innocuousness
of recently voided excreta, and the need for certain changes to be brought about in them, outside
the human body, before they become potent for harm; changes supposed to be effected in suitable
soils, given appropriate conditions of impurity and moisture. It was in the light of this theory of the
mode of spread of typhoid, that the sanitary measures of the latter half of the last century were undertaken,
measures which Dr. Demuth evidently thinks have not been without effect.
It is interesting to note in this connection a very curious remark made by von Drigalski, who
contributes a paper to the volume, and who, unlike Dr. Demuth, looks upon the older teaching with
complete disfavour. If, he observes, the typhoid organism grew in the soil, agricultural labourers must,
as a class, be held to be as much exposed to danger as nurses in hospitals or workers in laboratories,
and he adds that, in times of epidemic prevalence, it will, at least, be admitted that multitudes of
typhoid germs must finally lose their virulence in the soil of the churchyard. This institution of a comparison
of the relative risks of two kinds of employment is very instructive, particularly when considered
in the light of the actual figures at von Drigalski's disposal. Table 20, p. 471, shows noteworthy
incidence upon those engaged in agriculture, and this would, of course, be expected, in view of the fact
that the total population (of upwards of 2,000,000) dealt with, includes a considerable number of persons
thus employed. Only three doctors and two disinfectors, on the other hand, were attacked; one of the
doctors inoculated himself, accidentally, when engaged in experimenting, and he died. This incidence
is certainly not a heavy one, even on the two years' figures to which Table 20 relates, and apparently
the three doctors mentioned represent the total number attacked during the longer period of years (4¼)
to which von Drigalski refers. Five workers in the bacteriological institutes suffered, i.e., at the rate of
about one a year; the total number of workers (which must, however, have been considerable) is not
given. There are, moreover, references to typhoid fever in nurses; thus Klinger (p. 239) recorded
32 nurses attacked among 842 female sufferers (in whom the source of infection was believed to have been
discovered), i.e., between 3 and 4 per cent. There are, again, no means of determining whether or no
this percentage is in excess of the percentage of nurses to adult women generally. On p. 247 there is a
further reference to nurses, and it is stated that women constituted 78 per cent. of the total number
of nursing attendants attacked; the proportions of males and females in the total numbers at risk are
again not forthcoming. Altogether the data available for assessing the special risk to attendants on the
sick do not admit of any precise statistical analysis being made. The case cannot, however, be a convincing
one, for the statement appears (p. 200) that attendants on the sick were specially careful, and
for that reason they, as a rule, escaped. A soil theorist might conceivably find quite as much in
support of his thesis in the evidence cited by von Drigalski, as that writer believes that he himself finds
in support of his own contact theory.
It has already been noted that the fly hypothesis, which has found so much favour of late years
in this country and in America, is not regarded very seriously by the German reporters. Thus (p. 272)
the fact is referred to that the laboratories, in summer time, were invaded by large numbers of flies,
and, had conveyance of infection by these insects constituted a real danger, it would have been anticipated,
von Drigalski thinks, that many mishaps would have been recorded.
Again, a tendency to accept too readily evidence held to incriminate a water supply is commented
upon. Thus, on p. 21, it is rather naively noted that cases in one family or house, which might
be ascribed to contact, are oftentimes wrongly attributed to water, merely because the available supply
is one which cannot be regarded as above criticism ; and yet supplies of this kind, it is added, are not
uncommonly met with in rural districts. The writer goes on to hint that, in his opinion cases, which
are really due to contact are in a similar way, often on quite insufficient grounds, held to be due to
infected milk supplies. Again, on p. 16, the general absence of association between outbreaks of the
disease and areas of common milk supply is commented upon.
In tracing contact infection, however, apparently everything counts; blood, stool and urine
samples from all persons living in the same surroundings as a patient must be examined, and this means
(p. 186) not merely dealing with members of the same family, but with those dwelling in the same street
or even in the same district; such extension of the scope of enquiry becomes it is, however, reluctantly
agreed, in the case of towns of 15 or 20 thousand inhabitants, a counsel of perfection; the bacteriologist
finds himself adrift on a shoreless sea; he may, nevertheless, console himself, if a carrier cannot be
found, by concluding (p. 185) that it was a mere occasional disseminator of bacilli who was at fault,
and that he had ceased to void the germs at the time when the sample was submitted for examination.
Moreover, a positive result is satisfactory (p. 322) a negative result is held to prove nothing; or, as
an American writer, Dr. Overlander (Boston Medical and Surgical Journal, 13th July, 1913),
expresses it, there is a definite method by which we may determine whether a person is a typhoid
carrier, but there is no definite method by which we may determine that a person is not a typhoid
carrier. The German observers, working on the lines indicated, do not hesitate to attribute four-fifths of
their cases of known origin to contact. They calculate, p. 292, that their methods, if fully put into
execution, would reveal 4,300 new chronic carriers of typhoid fever, each year, among the German
population, and they are not in any way inclined to discount the value of such discovery by the consideration
that a large number of these persons would give no history of having ever suffered from typhoid
fever at all.