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medical officers of health, either directly or through the kind co-operation of
the Ministry of Health, has shown that no less than 44 cases have been
attributed to the same source in other areas affected, and there is little doubt
that this is by no means a full tally. In addition, there must have occurred
a considerable number with less severe symptoms in persons who failed to
seek medical advice, or received treatment for transient diarrhoea, etc.,
without the possibility of the presence of paratyphoid fever being recognised.
The delay in presenting this report has been due to my own absence
from dutv through an illness which commenced shortly after the detection
and removal of the chief factor in the outbreak, the subsequent administrative
control being in the capable hands of Dr. W. H. Brodie, Deputy Medical
Officer of Health. I have felt is desirable in attempting to give an account of
a very complicated investigation to describe in sequence the following-up of
false as well as of genuine clues, and the report will illustrate the fallacies
inherent in conclusions based on incomplete data, though naturally action
in the public interest may have to be taken on such imperfect information as
is available at the time.
First information of outbreak.
On September 5th, 1925, a case of paratyphoid (B) fever—a disease similar
to, but usually somewhat milder than, typhoid fever—was notified, as a
result of a positive blood agglutination test, and was admitted to the Borough
Fever Hospital. From the blood of this patient, Miss X, a pure culture of
the organism causing paratyphoid (B) fever was grown.
Miss X gave a history of having returned from a seaside holiday of a
fortnight's duration, one week before the onset of her illness on August
29th. In view of the normal incubation period of seven to fourteen days
for this disease, it was at first assumed that infection had occurred during
her absence on this holiday. When, however, it was ascertained that she
was employed at a confectioner's shop, a visit paid to the latter, largely for
the purpose of safeguarding the health of other employees and of customers,
revealed a remarkable state of affairs. It was founds—
(a) That Miss X was head assistant at the shop, and that her illness—
which began suddenly on August 29th with headache, abdominal pain, and
diarrhœa—was not the only case of illness among the shop staff;
(b) That nine out of a total staff of fifteen employed in various capacities
at the shop—including the manager and one of his sons—had had symptoms
similar in type, though varying in severity, with onset between August 31st
and September 2nd; and
(c) That four members of the manager's household not employed at the
shop, and living in a house entirely distinct from and not in the immediate
neighbourhood of the shop, had developed precisely similar symptoms between
August 30th and September 1st.
Of the nine persons among the shop staff showing these symptoms,
five—including the original patient, Miss X—were assistants in the shop and
restaurant for light refreshments attached to it, and all of these were, on
the day on which the investigation began, absent with illness, beginning in
the case of Miss X on August 29th, in two others on September 1st, and in the
remaining two on September 2nd. The illness, which had in the latter four
cases been labelled as influenza, was later proved by blood agglutination tests
to be paratyphoid (B) fever. The bookkeeper at the shop, who had gone on
holiday on August 31st, fell ill on that day, and when subsequently admitted
to the Borough Fever Hospital, was suffering from a well marked attack of
the same disease. The manager had slight transient indisposition on September
2nd, an errand boy began to be unwell on August 31st, and a second—
a son of the manager—on September 2nd.