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38
Thus there were only ten families (with 13 notified cases) on the list of regular
customers of the milk vendor in these four divisions. There were in addition 48
houses (fronting the east and west cross roads) not on the vendor's list, in which
15 cases occurred. It should be added that one of these houses was that of the
vendor himself. There were no cases in the nine houses receiving milk from
source X and fronting on the north and south cross road.
Special enquiry was made as to general shops, coffee shops and public houses
receiving milk from source X, and it was found that about a quarter of the total
daily yield of X milk (100 gals.), say 25 gallons of milk, was supplied to all three
kinds of shop. The small general shops alone received about one-tenth of the
total yield of milk (10 gals.). Thus, among the families receiving three quarters of
the daily yield of X milk only 13 cases occurred; while among those receiving the
remaining quarter of the milk, or not receiving the milk at all, 61 cases occurred.
Some further facts, moreover, came to light. In Area. A, 71 of the 77 houses
on the vendor's list of regular customers were in streets from which no notified
case was reported ; two of these streets—one with 24 and the other with 22 names
on the list of regular customers—had no case of typhoid. Again, in Area B, in
two blocks of buildings with 27 households on the vendor's list, no case of typhoid
occurred. It is worthy of note that Area C, which actually adjoins the milk
premises escaped with only 6 cases, and thus much more lightly than the other
three areas. In Area D, 12 of the 13 cases were in six streets, and the distribution
of the cases does not correspond with that of houses appearing on the list of
customers.
It is particularly important to observe that the streets and blocks of dwellings
referred to above (in which 24, 22 and 27 households appealing on the milk vendor's
list yielded no case of typhoid fever) included promises occupied by families less
poor than those living in the area as a whole, and this fact strikingly bears out the
general conclusion already noted that the sufferers in the outbreak were, as a rule,
those whose circumstances were straitened and whose consumption of fresh
milk was particularly limited.
Shellfish as a
possible
vehicle of
infection.
The facts adduced make it impossible to accept the view that milk from
source X was the cause of the exceptional prevalence.
Enquiry was made in the case of each sufferer as to consumption of shellfish.
Oysters were never, and mussels were only in three or four instances, referred to.
In twenty cases, however, there was a history of having partaken of cockles—but
no fewer than 54 cases were negative as to cockles. Considerable interest was at
an early stage aroused by the fact that of the twenty positive cases 15 had obtained
cockles from Southend. Analysis of the dates on which such cockle-eating took
place showed that in only two instances had Southend cockles been consumed
between September 1st and 10th, within which period the date of original infection
presumably occurred. In most of the other 18 cases the date of cockle-eating
was July or August, and thus some weeks or at any rate days, before that of presumed
infection. Enquiry was made in other parts of London as to cases of
typhoid associated with eating cockles and the medical officer of health of Southend
was consulted on the question. It was clear that cockles per se could not account
for the outbreak, though the possibility cannot be entirely excluded that in two
instances above referred to Southend cockles mav have been at fault.
Fish as a
possible
cause of the
outbreak.
Enquiry showed that of the 74 cases, 26 habitually consumed fried fish (i.e.,
fish sold ready cooked at a fried fish shop) and also fish cooked at home; 23 gave
a history of eating fried fish purchased at a shop only; 14 a history of eating fish
cooked at home only; in 9 cases (5 of which were doubtful cases of typhoid fever)
there was no information as to fish; in one case there was a direct negative as to
fish—and in this case the illness was eventually found not to be typhoid fever;
in another case it is stated " the girl does not like fish of any kind."
It will be seen, therefore, from the detailed examination of the statements