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THE CROYDON EPIDEMIC

THE LANCET

LONDON: SATURDAY, FEBRUARY 19,1938

THE outbreak of typhoid fever at Croydon lastOctober and November has already led to theillness of 310 persons, of whom 43 have died. Thecause is now established beyond doubt, and it isa cause that ought to have been prevented. Mr.HAROLD MURPHY, K.C., appointed by the Ministerof Health to inquire into the outbreak, attributesit to the infection of a fifty-year-old chalk well atAddington. His medical and engineering assessorssubstantially concur. Three factors, he says,coincided : there was constructional work in thewell; one of the workmen was a typhoid carrier ;and chlorination was omitted. Dr. HOLDEN, themedical officer of health, never knew that workwas going on in the well. He was never told that,while the work was proceeding, there would beno chlorination. Mr. BOAST, the borough engineer,responsible for the water-supply, was in ignorancetoo. Mr. BRANDRAM-JONES, the assistant waterengineer, overestimated the value of the filtrationplant and underestimated that of the chlorinator.

If the borough engineer failed to keep themedical officer of health informed of vitallyimportant points, he himself was unaware thattyphoid was being reported. The first case wasnotified on Oct. 27th, the second on Oct. 28th,and two more on Oct. 30th ; the borough engineerlearnt for the first time on Oct. 31st-and thenby a telephone message from an unofficial source-that there was any typhoid in the borough. OnNov. 1st the medical officer of health told all thelocal doctors that typhoid had appeared in SouthCroydon. He gave no’ details however. Medical

practitioners would have been greatly assisted in thetask of diagnosis if they had known that waterhad been identified as the source of the disease.But no such identification had taken place. Dr.HOLDEN was disinclined to suspect water until hehad eliminated other factors. The last substantialoutbreak of typhoid fever had been traced to milk.The evidence given by Dr. SUCKLING at the inquiryseems to have convinced Mr. MURPHY that watershould be immediately suspected and that, if thereis any priority in the course of searching for

possible causes, water should have the first place." I think," said Dr. SUCKLING, " that water

occupies the pre-eminent position with regard tothe spread of typhoid fever ... my view is thatthe majority of the epidemics of typhoid feverhave been due to the infection of water ratherthan food." This delay-Mr. MURPHY calls itonly a slight delay-in realising that water wasor might be the cause of the epidemic is happilythe sole criticism of Dr. HOLDEN which Mr.

MuRPHY regards as legitimate. The medicalofficer of health is described as a loyal, able, andindustrious servant of the Croydon corporation, aswell as a truthful and careful witness. His workin arranging for the treatment of the patientsthroughout the epidemic is highly praised.The details of Mr. MuRPHY’s report appear upon

another page. The lessons are obvious. Men whowork in wells must be physically fit. Mr. MuRPHYdoes not insist that, as a preliminary, bacterio-logical tests should be made of fseces and urine,but he regards a Widal blood test as a notunreasonable precaution. The provision for theworkmen at the Addington well to relieve them-selves was highly dangerous. The use of an

ordinary stable bucket for urine and the arrange-ments for it to be pulled to the surface speak forthemselves. So careless was the supervisionthat workmen were allowed to dig and use alatrine almost directly above one of the welladits. Apart from the obvious sanitary pre-cautions, there is the outstanding need of coördina-tion between the medical officer of health and theborough engineer. Dr. HOLDEN and Mr. BOASTworked under the same roof. If the former hadbeen told what was going on at the well, his advicewould have been promptly given and the outbreakmight have been averted. Dr. HOLDEN had

apparently no facilities for knowing that the

patients were all supplied with water from thesame source. Sir WILLIAM WILLCOX, who gaveevidence at the inquiry, stated that in all largeareas there should be a committee which would

represent the local doctors, so that in emergencythere might be constant contact with the medicalofficer of health and so that information of

symptoms and possible causes might be promptlyexchanged. Not less important, it seems, is theclear determination of responsibility for water-

supply. If a borough engineer has too many otherconcerns to be able to attend to what is perhapsthe foremost object of public health, some otherarrangement must be made for ensuring that thesupply of pure water is under expert supervision.Lastly, the time may now have arrived for raisingthe question whether the medical officer of healthis armed with all the powers which the nature ofhis duties may require.

THE STOMACH AND PERNICIOUS ANEMIA

A RELATIONSHIP between pernicious anaemia andlesions of the stomach was recognised by FENWICKin 1880 when he described gastric atrophy in

patients dying of the disease. Evidence of a

functional deficit in gastric secretion was broughtforward by W. B. CASTLE and his colleagues somefifty years later, in 1929. They showed that thestomachs of patients with pernicious anaemia wereunable to secrete a substance they called " theintrinsic factor," which normally reacts with an"extrinsic factor " present in ingested food. Inthe normal person the two factors between themproduce the precursor of the " pernicious-anaemiaprinciple," which is stored in (and obtained from)liver, and MINOT and MuRPHY had already proved