View report page

15
a railway strike. The following remarks were made at the close of the report on this outbreak (Ann.
Rep., 1911, Vol. III., p. 89):—
"This outbreak adds yet another instance to the now growing list of outbreaks in which
enquiry failed to show any other explanation than the consumption of fried fish. The circumstances
of the outbreak afford further illustration of the peculiar features which have been
described as typical of such outbreaks. There is the attack of a particular social class, the
peculiar age-incidence, the peculiar distribution of the cases in family groups, the same frequency
of the separate purchase of fish by the sufferer himself or herself, in cases in which only one
attack occurred in a house. But the present outbreak is very instructive inasmuch as it was
at first attributed to ice cream, and prima facie, there was something to be said for an ice cream
hypothesis. Analysis of the facts shows, however, that at least half the sufferers in the outbreak
had not eaten the suspected ice cream, and eight of the ten persons over twenty years of age
attacked had not partaken of this ice cream. Moreover, study of the topographical distribution
of the cases negatives an ice cream hypothesis."
In the Annual Report for 1912 the German report on Typhoid Fever, giving the results of Koch's
campaign, instituted in 1903, was reviewed, and it was pointed out that evidence of contact infection
was not forthcoming in London as was claimed to be the case in Germany, though there was agreement
as to the importance of food infection both here and there. The problem to be solved, it was urged,
"becomes one of determining the relative importance of the parts played, in 'indirect infection,' by
manipulation of food immediately prior to its consumption, on the one hand, and by exposure of food to
contamination in the gathering ground, foreshore, or estuary, on the other." It was added that " The
German reports themselves, in the evidence they yield of grouping of cases, of failure of spread in the
absence of new importations, and of comparatively slight incidence upon those specially brought in
contact with the sick, all confirm similar evidence obtained in this country, which tells strongly against
the view that mischief is done at a comparatively late stage in the history of the distribution of the
water or food."
In the 1913 Report the difficulties in accepting the bacillus carrier theory of spread of typhoid
were further considered, and it was concluded that: "Suspicion necessarily arises as to whether it may
not be necessary to look elsewhere than to these (typhoid) bacilli for the cause of typhoid fever."
In 1912 and 1913 no outbreak of typhoid was traced to fish. In 1914 a small outbreak occurred
(Ann. Rep., 1914, p. 20). In reporting upon this the following remarks were made:—
"It will be seen then that the available evidence points to infection being brought into
London in the large majority of cases by fish and shellfish coming generally speaking from a
considerable distance. The great improvements as regards sanitation effected in the last 50
years and particularly in the last 30 years have made London itself an eminently unfavourable
field for growth and cultivation of the typhoid poison; the areas from which infection is derived
are no longer near at hand, but are to be found on distant polluted foreshores and in remote
estuarial waters."
In 1914, as in the two preceding years, and as also in 1909, there was practically an entire absence
of the autumnal rise in typhoid fever; and in 1915 the continued low prevalence of typhoid with absence
of autumnal rise was again noted.
In 1916 the same phenomena recurred. An examination was made in the report of that year
(p. 7) of the 1915 report on the "Distribution of Plaice "by Dr. Masterman, and in particular it was
noted:—"It will be seen then that a considerable change has been brought about during the last 14 or
15 years as regards use of the Area (known as A:3) which includes 'the Continental nursery grounds and
close inshore waters where very small plaice abound.' The area has been increasingly abandoned by
English trawlers, and this has been especially the case since about 1907; indeed, about six years ago,
first the Hull, and then a year or two hater, the Grimsby boats, altogether discontinued going there."
Certain facts observed with reference to the relationship of autumnal to annual prevalences in
the three main fishing ports, in the principal towns and in certain county areas in England and Wales,
were considered ; the conclusions drawn from this examination were:—
"The whole question of variations in the type of the typhoid curves in different parts of
the country merits close study, but three facts are at any rate clear. First, typhoid fever reached
a high level in London in the years when there was a maximum use of the A3 area. Second, a
decline followed upon the gradual disuse of this area. Third, a further decline with smoothing
out of the autumnal prevalence has occurred in the last eight years, save in 1908, 1910 and 1911,
when there were small autumnal outbreaks, traced to small ungutted flat fish.
"The facts at any rate justify discouragement as a source of supply to this country of
under-sized plaice and dabs from the mouth of the Elbe.
" On a review of all the facts as to disuse of suspected sources of supply to this country of
shell-fish and of fish, it will be apparent that the great decline of recent years in prevalence of
typhoid fever has proceeded practically pari passu with abandonment of consumption of shellfish
and fish from polluted sources, and, with removal of layings, etc., to a distance from sewer
outfalls. In particular it should be noted that the classical reports of Dr. H. T. Bulstrode, and
the adoption of the precautionary measures outlined in them, must be regarded as having been
very largely responsible for the great reduction in the prevalence of and mortality from typhoid
fever brought about in the last 20 years. Just at the time, however, when the carrying into
effect of epidemiological teaching was beginning to exert appreciable influence, aliew