View report page

12
Of 172 cases in which a possible source of infection is mentioned, reference is made in 30 to shellfish,
in 20 to fish, in 10 to watercress and in 23 cases to other food. Infection is attributed in 31 instances
to contact with other cases, and in 34 cases the disease was thought to have been contracted during
residence outside the County
Antityphoid
inoculation.
Reference was made last year to reports on Antityphoid Inoculation of Civil Populations"
in various parts of the world; and more particularly to some French and American experiences relating
to groups of men and women coming under review in particular institutions and in "a number of
localities." These results were contrasted with those yielded by the London population male and
female, at ages 20-45. The last named data did not, it was pointed out, "lend support to the view that
inoculation has afforded any appreciable lasting protection to the men at risk." A paper by Professor
Charles Achard has recently been published (Lancet April 15th, 1922), giving a " Detailed Statistical
Study" of the figures published by M. Chauffard and M. Em. Sergent; also Professor Achard's own
experiences. The numbers dealt with are, however, quite small. The first series, that of M.
Chauffard, contrasts 11 men and 42 women attacked in 1912-13 with 10 men and 23 women attacked
in 1918-20. The average age in the men had fallen from 24 years before the war to 17½ years in 1918-20;
in the case of the women the average age remained the same in both periods, 27 years. In the second
group, that of M. Sergent, there were 18 men and 9 women (average ages 27 and 26 respectively), attacked
during 1911-13, and 4 men and 13 women (average ages 24 and 26 respectively) attacked in 1918-20.
" These figures differ from those of M. Chauffard," says Professor Achard, "in that they show a much
reduced total male incidence relative to that of females." Professor Achard's own figures relate to
30 patients, 21 women and 9 men—3 of the women (14 per cent.) and 3 of the men (33 per cent.) were
under 20 years of age. In the absence of particulars as to the age constitution of the populations from
which the patients in the three series were drawn, it is difficult to judge how far significance can be
attached to the altered average age in the men as compared with the women.
The London figures for 1921, on the other hand, which relate to the civilian population as a
whole, confirm the impression yielded last year. In 1921 there were 65 cases among men aged 20-45
and 92 among women of the like ages. These figures represent rates which, having regard to the
calculated excess of the numbers of women over men at those ages in the London population, do not
very markedly differ in the two sexes.
It is interesting to find that Professor Achard states "It is particularly in towns, where outsiders
make short stays, and in certain bathing resorts, that typhoid is prevalent"; hence he says,
" it is in these places that vaccination should be widely applied." The experience in this country corroborates
the former finding ; but while the premises are thus the same an entirely different conclusion
must follow; here (as in France also) in towns and in certain seaside resorts typhoid is apt to be prevalent;
but typhoid in this country is as a rule food-borne, in fact attributable to infected fish and
shellfish; there is in fact, no evidence, so far as London is concerned, that vaccination protects against
the incidence of typhoid, for the figures show very much the same incidence of the disease upon men
aged 20-45, a large proportion of whom were vaccinated during the war, and upon women 20-45 who
only in rare instances had been vaccinated.
Water and
food borna
typhoid
fever.
In last year's report reference was made to the instructive figures given in the ninth annual
report on " Typhoid in the Large Cities of the United States in 1920." The corresponding tenth
annual report is now available (Journal of the American Med. Assoc., 1922, p. 890). There is a slight
set back manifested in these large cities during the last 10 or 15 years. The report states: "There
is no doubt that 1921 was relatively speaking a 'typhoid year.' Not only did the majority of cities
experience an increase—although generally slight—over the typhoid rate of the previous year, but
the Honour Roll, including cities with a rate under 2.0 per 100,000 numbered only 5, as against 10 in
1920 and 8 in 1919. Cities with a rate over 10.0 increased in number from 5 in 1920 to 11 in 1921."
The rate for all the cities was, however, "less than half the rate for 1916." The decrease is mainly
attributed to improvement, and in many cases to chlorination, of water supplies. In some instances
" immunisation was given to persons exposed to typhoid cases, but relatively few persons in the general
civilian population voluntarily sought immunisation." Stress is laid upon the fact that many persons
were infected in "out of town localities." Mention is made, too, of contamination of food, of milk outbreaks
and of an outbreak at a "country club luncheon," but there is a curious absence of reference to
shellfish infection save in the case of New York where five cases were so ascribed. Allusion is made
in the report to risk connected with indulging in swimming in polluted harbour water in New Haven,
Connecticut, a place familiar, as being associated with the original oyster outbreak reported upon by
Professor Conn. Judging by other reports from America, however, a large measure of attention has been
devoted to the question of pollution of tidal waters with special reference to shellfish bearing areas.
It may be that the diminution of typhoid in American cities is largely ascribable to improvement in this
respect, as is undoubtedly the case in this country.
Typhoid
fever
caused by
shellfish.
The practical issue in regard to typhoid fever, which presses for decision at the present time, is
whether the control over spread of this disease is to be maintained and further strengthened by working
on the epidemiological lines, first laid down by Dr. Bulstrode in his classical oyster report of 1896,
or on rival bacteriological lines, in compliance with which the stress is placed upon the supposed risk
from healthy carriers and the need of combating this by vaccination. In a paper read before the Metropolitan
Branch of the Society of Medical Officers of Health last year (Public Health, December, 1921),
an attempt was made to show that the mischief responsible for typhoid fever in London during at any
rate the last 25 years had been traced to remote estuaries and distant foreshores, and that full control
of the disease is to be secured by cutting off polluted supplies of fish and shellfish, and not by attempting
to segregate healthy carriers of bacilli, or advocating the general practice of antityphoid vaccination.
This thesis may be supported by the following experience from America.