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38
Annual Report of the London County Council, 1912.
In this summary of the German reports, no reference has hitherto been made to the special
bacteriological questions, which, indeed, occupy the major portion of the volume. The description
of the technique employed, and the careful account given of certain anomalous cultural and serological
peculiarities observed in dealing with particular strains of typhoid bacilli are, however, full of
interest. Part IV., written by Dr. Rimpau, which deals with paratyphoid fever and dysentery,
appears especially deserving of close attention. There occurs (p. 562) a remarkable discussion of
the question whether discovery of the presence of a chronic carrier of paratyphoid bacilli, in the
near neighbourhood of a sufferer from paratyphoid fever, warrants the conclusion that the
latter was infected by the former. Dr. Rimpau says the two may have been infected quite independently
of one another, or both may have been infected from one and the same common source, one
person developing the disease, the other merely becoming a healthy carrier. Finally, he says, the
possibility must be kept in mind that the sick person may have excreted bacilli before his illness developed,
and that the healthy carrier may thus have been infected by him, instead of his having been infected
by the healthy carrier. The bearing in mind of these possibilities, in the case of typhoid fever and the
typhoid fever bacillus, might tend perhaps to reduce somewhat the large proportion of carriers of that
disease, attributed to contact in these German reports. Dr. Rimpau, moreover, gives (p. 544-546) a full
account of the special difficulties encountered by reason of the occurrence of paratyphoid bacilli in the
excreta of healthy persons, and also in persons presenting symptoms of very various character, food
poisoning, influenza, liver disorders, and scarlet fever. On p. 546 he refers to the fact that in swine
fever an organism, which closely resembles the paratyphoid bacillus, is commonly found, but that it
is not this organism, but a "filterpasser," that is now regarded as the cause of the disease. Dr. Rimpau
speculates as to the possible bearing of this last-mentioned view upon the anomalous and perplexing
bacteriological results which he has to record in reporting upon paratyphoid fever.
* These German reports have been referred to in some detail, as they illustrate very copiously a
particular modern point of view. Thus, if the analytical statement of all the German cases be
examined, it transpires that, out of a total of 10,149, in 5,254 of which a source of infection was recorded,
no fewer than 4,202 cases were ascribed to contact, 399 to water, 309 to milk, 141 to other foods, 39
to laundry work, 103 to nursing the sick, 5 to soil infection, 26 to direct excretal contamination, and
11 to laboratory infection. The absence of references to shell fish is very remarkable, but the large
number ascribed to contact can perhaps be understood, in the light of the explanations which have been
collected from the reports, of the principles upon which such ascription has oftentimes been based; in
this large series of 10,000 cases, it will be noted that the laboratory and nurse sufferers assume proportions
to the total numbers which cannot greatly exceed the percentages of laboratory workers and of
nurses respectively, in the total populations at risk.
It is very instructive to compare the experience gained in South West Germany with that forthcoming
from towns like London and Belfast. In all three there has been marked decline of typhoid
fever in recent years, as will be seen on reference to diagram U. In Belfast this decline has been
attributed by Dr. Darra Mair to disuse of cockles from a neighbouring sewage polluted foreshore.
Contact infection Dr. Mair relegates to quite a subsidiary place, while he left no role at all for the
healthy carrier to perform. In South West Germany the influence of shell fish is practically ignored,
though there is an isolated mention of fish ("Seebarsch"), in connection with some cases of paratyphoid
fever (p. 571); the part played by the healthy carrier, however, is deemed, as has been seen,
to be one of extremely great importance. In London the methodical examination of excreta,
on the lines practised in Germany, has only been carried out in a few localities, and in them a
good deal of difficulty has been experienced in obtaining the necessary material. Much careful work
has been undertaken by London medical officers of health, who have endeavoured to trace sources of
infection in individual cases, and the series of reports, to which the present report belongs, has contained
a summary year by year of the results which have been obtained. Only one outbreak of typhoid fever,
that of 1895 in Plumstead, has been traced in recent years to milk in Lonndon. Sir Shirley Murphy
reported in 1894, and again later, upon the relation of typhoid fever prevalences to floods; several
cases, moreover, have been ascribed to contact infection, and this has been more particularly the case
since the trend of thought in Germany has influenced opinion over here. There have, further, been a
large number of cases attributed to food infection; the kind of food implicated being, as a rule, shellfish,
fried fish and, in some instances, ice cream or watercress. Many of these foods, have moreover,
been of a kind which would bring them within the category of "trash bought in the streets," to adopt
the description applied by Dr. Niven, of Manchester, some years ago to certain materials sold in the poor
quarters of that town. There is a remarkable point about the London sufferers, and here, at any rate,
there is agreement with observations made among the sufferers in South West Germany (p. 223 of the
German report): those attacked, as a rule, have belonged to the poorer classes. In the case of London
it has not perhaps been so much the classes which are quite the lowest in the scale, the A and B
of Mr. Charles Booth's classification, as the classes just above them, C and D, that have been affected.
Londoners in these classes, it has been found, consume, as a rule, more than one of the varieties of food
which have from time to time fallen under suspicion, and, in particular oubreaks, question has arisen as
to which, if any, of the kinds of food referred to has been concerned in causing spread of infection.
Thus, in 1911, two prevalences of typhoid fever were developed almost simultaneously in London, the
one prevalence (which was somewhat widespread all over the town) affected only persons who had
recently been at Ramsgate and had partaken of cockles there, the other (a more extensive but strictly
localised prevalence) was traced to the consumption of fish from a fried fish shop. It is noteworthy
that several of the sufferers, in this last-named prevalence, had also partaken of ice cream obtained
from a particular vendor, but careful analysis of all the facts clearly showed that fish and not ice cream
was at fault. Similarly, in other outbreaks, question has from time to time arisen as between mussels,
and fish, watercress and fish, and so forth.