View report page

10
Seven cases occurred in August in a household in Greenwich. Six were notified on the 22nd,
and a seventh on the 24th. Dr. Annis ascertained the date of onset of illness of the various members
of the family, and suggested that the cause might be an illness of the mother dating from 1st August. A
boy of 16 was ill the next day; thereafter, on the 15th, two boys, aged 11 and 6, and a girl of 5 became
ill, and again about the 21st two other children sickened. Dr. Annis was not able to trace the source of
infection, and nothing throwing light thereon was ascertained from the patients while in the M.A.B.
Hospital. All the cases were described as paratyphoid.
Five cases were reported in one household in Poplar ; the first on 13th July, followed by others
on 7th September and 8th and 23rd October. The only suggested source for the first case, that of a boy
of 14 years, was bathing in the Thames. In another case occurring in the same street on 21st August,
that of a girl of 11, infection was attributed to eating monkey-nuts found floating in the water while
bathing in the Thames.
The four cases were notified in one house, in Camberwell; three on 2nd July, and another on
7th July. Dr. Stevens found that one of the cases had been diagnosed some time earlier as influenza and
pneumonia; but, no progress being made by the patient, a blood test was made which gave a " positive
result."The other cases were, thereupon, attributed to this "missed case."
Attention was drawn by Dr. Sandilands to the occurrence of cases of typhoid fever in Kensington
chiefly among domestic servants, during June and July. The cases were investigated by Dr. Forbes,
but nothing was elicited establishing any common cause of infection. No corresponding excessive
incidence occurred elsewhere in London during the same period.
The number of cases in which particulars were obtained by borough medical officers of health as
to possible source of infection was 170. Fish and shell-fish are mentioned in 37 instances; in 23 cases
the disease was said to have been contracted outside London; 43 cases were ascribed to contact infection
(including four nurses); 6 were attributed to river bathing; 3 to drainage and 4 to "drinking water."
The proportion of cases assigned to the various sources mentioned shows no marked variation from that
of last year.
No groups of cases attributed to paratyphoid occurred, as was the case in London and elsewhere
in 1918, at the time when influenza was widely prevalent.
The behaviour durinvhe last half century.
Typhoid fever was only distinguished from typhus and continued fever in the returns of the
of Registrar-General in 1869. There is, therefore, very great uncertainty as to the extent of its prevaearly part of the 19th century and even up to the fifties and sixties; there is still some uncertainty
indeed as to the amount of the disease as late as the seventies; and even, though in markedly less degree,
the early eighties, when it was still occasionally confused with typhus fever. When, at length, typhoid
fever came to be more carefully studied and more precisely diagnosed in the late eighties and nineties,
typhus had almost completely disappeared, and at that time it was the generally accepted belief that
sewer and drain air, water and milk were ordinarily concerned in its spread. During the twenty years
in question great improvements in sewerage and drainage, in water, and to a less extent in milk supplies,
had been brought about, and corresponding in time with all this there was a notable decline in typhoid
fever. There seems, on the whole, to be more reason for attributing the major part of this decline to
improved water supplies than to better sewerage or drainage, or to better regulation of milk supplies.
It is noteworthy that careful scrutiny of the recorded epidemic prevalences shows—;first, as regards
water outbreaks, that in the early prevalences shallow wells, then later deep wells and river supplies,
and later still larger public supplies of water, tend to be incriminated ; this is no doubt in part accounted
for by the fact that big waterworks undertakings were steadily displacing smaller local supplies throughout
the period under review ; even so the decline in the proportionate number of outbreaks ascribed to
polluted water is remarkable ; and, furthermore, it cannot be doubted, in the light of the knowledge
gained in the last twenty or twenty-five years, that question seriously arises as to the correctness of
attributing to water some of the outbreaks on the large scale, such as those at Bangor (1882), King's
Lynn (1891-92 and 1897), the two Tees Valley epidemics of 1890-91, the two outbreaks at Worthing in
1893, and the Newport outbreak of 1894 ; in some, certainly, of the major water prevalences, and probably
in many both of the earlier and later smaller prevalences attributed to wells and streams, infected
shellfish or fish must in fact be suspected to have been the real cause of the outbreaks. In the case of the
particular outbreaks above mentioned, the careful investigations made at the time by the Local Government
Board Inspectors concerned, make it clear to the present-day reader that the writers of the reports
were fully realising that there remained something unexplained by a water hypothesis of causation. Again,
secondly, with regard to milk, there was a falling off observable, some twenty years ago, in the proportion
of milk outbreaks of typhoid, as compared with the number of outbreaks of scarlet fever and of diphtheria
attributed to milk. Here, again, doubt must be felt as to the correctness of ascribing many of the socalled
milk outbreaks of typhoid to milk infection. In the earlier years, i.e., at a time when milk outbreaks
of typhoid were (proportionately to other milk epidemics) relatively common, no inquiries were,
of course, made with regard to shellfish; further, in some of the later milk outbreaks, as has been shown
elsewhere (Roy. Soc. Med., Vol. IV., Epidem. Sect., pp. 108 to 117), the evidence held to incriminate the
milk is far from being conclusive; resting as it does rather on the a posteriori discovery of healthy carriers
of typhoid bacilli, who it is thought may have infected the milk, than on a priori demonstration of
excessive incidence, beyond that which chance might explain, upon the consumers of the particular
milk in question. It may be added that careful enquiry in London during the last 25 years has only
brought to light one outbreak of typhoid fever, in which a prima facie case against milk has been clearly
established, and even in that instance the conclusion cannot be regarded as free from doubt, as the
question of fish or shellfish infection was necessarily (the outbreak occurring as long ago as 1895) not