It is to meat, bread, beer and tinned foods that I desire to invite attention, as it does not seem that any outbreaks of the disease have been traced to such sources. For although it may be true that the temperature reached in perfect cooking, baking, brewing, &c., absolutely destroys enteric bacilli or even spores, it is possible that, in India as elsewhere, these processes are not always perfectly carried out, as regards the temperature reached, and hence some bacilli or spores may escape destruction, and so lead to an outbreak of the disease. Moreover, meat, bread, beer, &c., may become infected after exposure to high temperatures before being consumed. Hence perhaps a word of warning regarding possibility of infection by such articles may not be out of place. I. Meat.?It seems hardly possible that meat eaten hot, immediately after being cooked, as it usually is, should be capable of conveying infection. Underdone, or cold meat, however, cannot be regarded as equally free from suspicion. These are not often seen in the soldiers' kitchen or barrack-room, but are frequently found in tlie1^ coffee shop, temperance rooms, &c. II. Bread.?The soldiers' bread cannot be regarded as free from suspicion, for, first it may be insufficiently baked, and secondly, it may become infected after baking before being consumed by the soldier. In scientific baking the central portion of each loaf is exposed to a temperature of 110?C., and therefore all bacilli or spores which may have been in the flour, or yeast, or water, are destroyed. But it is questionable whether this temperature is in all cases reached in baking. For it is not unusual to find in a batch of 200 or 300 loaves a good many which are plainly sodden and underbaked. Hence bacilli, in the water or yeast or flour used, escape destruction, and being eaten by the soldier produce enteric fever. It is evident that bread prepared with infected water ma}7, in this way, cause the disease, as water is a well-known medium of infection. The flour from which bread is made is not, howAnd ever, so generally regarded with suspicion. it comes and whence remembered it is when yet through whose hands it passes in India, I think it should always be looked on with grave sus?
SOME POSSIBLE SOURCES OF INFECTION IN ENTERIC FEVER, By MATHEW D.
O'CONNELL, M.D.,
Bde.-Surgn.-Lt.-Col., A.M.S., Murree,
When enteric fever breaks out amongst British in India the water-supply (including soda water, &c.), milk and butter are at once suspected, and carefully examined, as possible Other articles of the solsources of infection. diers' food, such as bread, meat, beer and tinned food do not seem to be regarded with so much
troops
suspicion.
The reasons for tbis difference are probably that outbreaks of tbis disease in England are so frequentty traced to infected water, milk, &c., that we naturally turn at once to the investigation of these so frequent sources of infection. And secondly, knowing that bread, meat, beer and tinned food are, in the courseof preparation, exposed to a temperature, at which, .it is said, bacilli and even spores cannot live, these articles safe. are commonly considered With regard to the first named I do not, in this paper, intend to refer to water, sodawater, milk and butter as sources of infection as their importance is fully recognised in India as at home.
picion.
-l
?
The soldiers' bread is supposed to be made with wheaten flour, but the common adulterations of wheaten flour are the cheaper barley, maize and millet, and I have no doubt they are freely used in India. In addition to this adulteration, the flour may be bad or contain fuggi. Such flour is believed to cause disease in man, such as indigestion, constipation, diarrhoea, ergotism, and even the disease known as pellagra,
Oct.
1898.]
common
SOURCES OF INFECTION IN ENTERIC FEVER: O'CONNELL.
375-
place, it is quite possible that temperature may not destroy spores or
And in the next
amongst the peasants in Italy, Spain, such
a
and the south of France. even bacilli. Of this disease I have 110 personal experience, Bacteriology, as often said, is but in its inbut it apparently is an erythema of the skin fancy, and the conditions of exposure to air,, indigenous to hot countries, lasting from two to sunlight, temperature, &c., which are favourable four weeks. The eruption appeal's to vary from or unfavourable to the growth, &c., of bacilli, the wheal of urticaria to a spot as small as the and under which these interesting bodies live eruption of enteric fever. It is often accom- and die, seem to be little, if at all, known even panied by fever, diarrhoea and lung complica- to the most experienced bacteriologists. tions, and followed by typhoid fever, stupor, For instance, bacteriologists were, for a time, melancholia with suicidal tendencies. Relapses certain that some species ot bacilli were aerobic are not unfrequent. Further investigation and others anaerobic. I have often seen cases in our Indian hospihowever showed that, that man}7 jierobic bacilli tals which, if the above description is even could live and grow and multiply in the absence nearly correct, might fairly be regarded as of air or oxygen. Bacteriologists were, therefore, pellagra. Indeed it has more than once occur- forced to admit that rerobic bacilli, are sometimes, me that of this red to cases disease actually do as they term it, "capably' anaerobic. find their way into our hospitals in India and In like manner it is very probable that with appear in our statistical returns under the pseu- wider experience and improved methods bactedonym of enteric fever. For maize, a fungus may find that bacilli, or even spores, riologists in which is said to be the cause of pellagra, is which are now believed to be killed by a templentiful in India, is much cheaper than wheaten perature of 100?G., may be capable of living at flour, and is used to adulterate it. much higher temperatures. Of course I do not refer to unmistakable Now the use of yeast in bread-making is cases of enteric, or those where "post-mortem an important point of difference between the examination has confirmed the diagnosis, albread of the British soldier and the chupattie though Hebra recorded cases of erythema (to of the sepoy. The bread used by the former which pellagra is closely allied) in which red is fermented; the bread of the latter is not. rings of congestion were found in the small in- Fermented bread apparently is a more probable testine after death. But I refer to outbreaks of It source of infection than unfermented bread. enteric fever in which the mortal it}' is suspiciwas Pasteur, I think, who pointed out the danger ously low, and the disease runs a mild course. of contamination by other, possibly pathogenic, At such times bacteriological examination of organisms during fermentation, especially high from the flour which it is or underbaked bread, fermentation. made, may not oidy show it to be a source of Perhaps this difference between the bread of infection of enteric fever, but also make clear the European, and the bread of the native, may, that a certain percentage of the cases of con- in some degree, explain the difference in the tinued or remittent fever treated in our hospiprevalence of enteric amongst the two classes. tals are really of the nature of, or closely allied We have indeed been given a variety of to, pellagra. reasons as to why the native escapes the Besides the luater and flour used in the preenteric fever which is so prevalent amongst paration of the soldiers' bread, there remains to It was said the native is naturally be considered the still more important yeast as a Europeans. or immune, acquires immunity by contracting possible source of infection. In yeast we have the disease in youth. But it is known that the a living organism said to be of the same nature, native is not immune, as cases of enteric fever which viz., a ferment, as the bacilli produce in natives have been recorded by officers of the disease. Hence it is to be presumed that where Indian Medical Service. And it is a common yeast lives, bacilli may also live. So that if experience that one attack of enteric fever does enteric bacilli find their way into yeast, as may not alwa}Ts protect from second attacks of* the very possibly occur in bakeries in India, they disease in Europeans. Why should it do so in find a medium in which they thrive. natives ? Whether the skin is black or white, It may be objected that all micro-organisms the races are anatomically, physiologically and do not thrive under the same conditions of expathologically the same. Hence 1 believe that posure to air, temperature, &c., and that even if we must look for some difference in food and enteric bacilli find their way into yeast, it does drink to explain the difference in degree in not matter, for in the process of baking, they which natives aud Europeans suffer from this will be exposed to a temperature of at least disease. 100?C. which will destroy them. It may be said that fermented bread cannot It is not certain, however, that this temperabe the source of infection, for, if it is, the disease ture is always reached in baking, for as previouswould be far more prevalent at home than it is ly pointed out, it is common to find many loaves known to be. sodden and underbaked.
THE INDIAN MEDICAL GAZETTE.
376 The
surroundings of bakeries at, home are, however, very different from those in this country, as any one who takes the trouble to visit a regimental bazaar bakery will probably admit, and it is not suggested that fermented bread of itself is the cause of the disease, but that it forms
an excellent medium for the culture of the bacillus. Other facts that suggest a possible connection between enteric fever and bread stuffs are as
follows:? In England there is one harvest of grain or bread stuff in the year, while in India there are two such harvests. In England enteric has one season of maximum prevalence, viz., October-November, and declines throughout the year till the following In India enteric fever has two seasons autumn. of maximum prevalence, one in April and the second in August, and declines in the other months of the year. Now both in England and India these seasons of maximum prevalence of enteric fever seem to follow the seasons of cutting or saving the harvest of grain or bread stuffs in a constant invariable manner. In England the wheat crop is cut in August, and presumably soon after is placed in the market. The maximum prevalence of enteric fever follows invariably in October-November. This of course may be only an unimportant coincidence. But when it is remembered that the two seasons of maximum prevalence of the. disease in India similarly follow the two harvests of bread stuffs, the sequence seems peculiar and worthy of
investigation.
Thus in India the first harvest (wheat, &c.) is saved in May or June, and one season of maximum prevalence of enteric follows in August. The second harvest (including some grain, the flour of which is used to adulterate wheaten flour) is saved in November or December, and is followed in the early part of the year by an increase of enteric fever which reaches its second maximum of prevalence in
April.
This seasonal increase of enteric cannot be due to seasonal influence directly, else why should it prevail during the cold of OctoberNovember in England, whilst in India it is during the heat of April and of August that it
prevails.
But if the flour of
new
wheat and other
grain
adulterate it, or the fermented bread made from it, is a possible source of infection, it is apparent how seasonal influence may indirect?used
to
ly explain the varying prevalence of enteric fever throughout the year both in England and
For it is just after the flour of each harvest is placed in the market that enteric fever becomes most prevalent, and it then declines until the following harvest is saved. in India.
[Oct.
1898.
Such flour may be bad or contain fungi that disease, such as pellagra, or be infected with the enteric bacillus from the hands through which it passes. If bread made from this flour is insufficiently baked, it forms an excellent medium for the growth and multiplication of the bacilli. Now there are many places in which flour may become infected with the bacillus of enteric fever,?in the cultivator's home, in the wheat stores, in the flour mills, in the bazaars, in the bakeries where men, not always too clean or perhaps recently from homes where relatives are suffering from the disease, are employed as sifters, kneaders, bakers, &c. It can be seen then if the flour, the water or the yeast used in making bread should become infected, how it becomes absolutely necessary that the baking should be perfect, that is, that the bread should be exposed to a temperature which will not merely arrest fermentation but will assuredly destroy any spores which ma}7 have found their wa}7 into it. In a subsequent paper I propose to invite attention to beer and tinned food as possible sources of infection. cause
(To
be
continued.)
SOME POSSIBLE SOURCES OF INFECTION IN ENTERIC FEVER, By MATHEW D.
O'CONNELL, M.D.,
Bde.-Surgn.-Lt.-Col., A.M.S., Murree,
When enteric fever breaks out amongst British in India the water-supply (including soda water, &c.), milk and butter are at once suspected, and carefully examined, as possible Other articles of the solsources of infection. diers' food, such as bread, meat, beer and tinned food do not seem to be regarded with so much
troops
suspicion.
The reasons for tbis difference are probably that outbreaks of tbis disease in England are so frequentty traced to infected water, milk, &c., that we naturally turn at once to the investigation of these so frequent sources of infection. And secondly, knowing that bread, meat, beer and tinned food are, in the courseof preparation, exposed to a temperature, at which, .it is said, bacilli and even spores cannot live, these articles safe. are commonly considered With regard to the first named I do not, in this paper, intend to refer to water, sodawater, milk and butter as sources of infection as their importance is fully recognised in India as at home.
picion.
-l
?
The soldiers' bread is supposed to be made with wheaten flour, but the common adulterations of wheaten flour are the cheaper barley, maize and millet, and I have no doubt they are freely used in India. In addition to this adulteration, the flour may be bad or contain fuggi. Such flour is believed to cause disease in man, such as indigestion, constipation, diarrhoea, ergotism, and even the disease known as pellagra,
Oct.
1898.]
common
SOURCES OF INFECTION IN ENTERIC FEVER: O'CONNELL.
375-
place, it is quite possible that temperature may not destroy spores or
And in the next
amongst the peasants in Italy, Spain, such
a
and the south of France. even bacilli. Of this disease I have 110 personal experience, Bacteriology, as often said, is but in its inbut it apparently is an erythema of the skin fancy, and the conditions of exposure to air,, indigenous to hot countries, lasting from two to sunlight, temperature, &c., which are favourable four weeks. The eruption appeal's to vary from or unfavourable to the growth, &c., of bacilli, the wheal of urticaria to a spot as small as the and under which these interesting bodies live eruption of enteric fever. It is often accom- and die, seem to be little, if at all, known even panied by fever, diarrhoea and lung complica- to the most experienced bacteriologists. tions, and followed by typhoid fever, stupor, For instance, bacteriologists were, for a time, melancholia with suicidal tendencies. Relapses certain that some species ot bacilli were aerobic are not unfrequent. Further investigation and others anaerobic. I have often seen cases in our Indian hospihowever showed that, that man}7 jierobic bacilli tals which, if the above description is even could live and grow and multiply in the absence nearly correct, might fairly be regarded as of air or oxygen. Bacteriologists were, therefore, pellagra. Indeed it has more than once occur- forced to admit that rerobic bacilli, are sometimes, me that of this red to cases disease actually do as they term it, "capably' anaerobic. find their way into our hospitals in India and In like manner it is very probable that with appear in our statistical returns under the pseu- wider experience and improved methods bactedonym of enteric fever. For maize, a fungus may find that bacilli, or even spores, riologists in which is said to be the cause of pellagra, is which are now believed to be killed by a templentiful in India, is much cheaper than wheaten perature of 100?G., may be capable of living at flour, and is used to adulterate it. much higher temperatures. Of course I do not refer to unmistakable Now the use of yeast in bread-making is cases of enteric, or those where "post-mortem an important point of difference between the examination has confirmed the diagnosis, albread of the British soldier and the chupattie though Hebra recorded cases of erythema (to of the sepoy. The bread used by the former which pellagra is closely allied) in which red is fermented; the bread of the latter is not. rings of congestion were found in the small in- Fermented bread apparently is a more probable testine after death. But I refer to outbreaks of It source of infection than unfermented bread. enteric fever in which the mortal it}' is suspiciwas Pasteur, I think, who pointed out the danger ously low, and the disease runs a mild course. of contamination by other, possibly pathogenic, At such times bacteriological examination of organisms during fermentation, especially high from the flour which it is or underbaked bread, fermentation. made, may not oidy show it to be a source of Perhaps this difference between the bread of infection of enteric fever, but also make clear the European, and the bread of the native, may, that a certain percentage of the cases of con- in some degree, explain the difference in the tinued or remittent fever treated in our hospiprevalence of enteric amongst the two classes. tals are really of the nature of, or closely allied We have indeed been given a variety of to, pellagra. reasons as to why the native escapes the Besides the luater and flour used in the preenteric fever which is so prevalent amongst paration of the soldiers' bread, there remains to It was said the native is naturally be considered the still more important yeast as a Europeans. or immune, acquires immunity by contracting possible source of infection. In yeast we have the disease in youth. But it is known that the a living organism said to be of the same nature, native is not immune, as cases of enteric fever which viz., a ferment, as the bacilli produce in natives have been recorded by officers of the disease. Hence it is to be presumed that where Indian Medical Service. And it is a common yeast lives, bacilli may also live. So that if experience that one attack of enteric fever does enteric bacilli find their way into yeast, as may not alwa}Ts protect from second attacks of* the very possibly occur in bakeries in India, they disease in Europeans. Why should it do so in find a medium in which they thrive. natives ? Whether the skin is black or white, It may be objected that all micro-organisms the races are anatomically, physiologically and do not thrive under the same conditions of expathologically the same. Hence 1 believe that posure to air, temperature, &c., and that even if we must look for some difference in food and enteric bacilli find their way into yeast, it does drink to explain the difference in degree in not matter, for in the process of baking, they which natives aud Europeans suffer from this will be exposed to a temperature of at least disease. 100?C. which will destroy them. It may be said that fermented bread cannot It is not certain, however, that this temperabe the source of infection, for, if it is, the disease ture is always reached in baking, for as previouswould be far more prevalent at home than it is ly pointed out, it is common to find many loaves known to be. sodden and underbaked.
THE INDIAN MEDICAL GAZETTE.
376 The
surroundings of bakeries at, home are, however, very different from those in this country, as any one who takes the trouble to visit a regimental bazaar bakery will probably admit, and it is not suggested that fermented bread of itself is the cause of the disease, but that it forms
an excellent medium for the culture of the bacillus. Other facts that suggest a possible connection between enteric fever and bread stuffs are as
follows:? In England there is one harvest of grain or bread stuff in the year, while in India there are two such harvests. In England enteric has one season of maximum prevalence, viz., October-November, and declines throughout the year till the following In India enteric fever has two seasons autumn. of maximum prevalence, one in April and the second in August, and declines in the other months of the year. Now both in England and India these seasons of maximum prevalence of enteric fever seem to follow the seasons of cutting or saving the harvest of grain or bread stuffs in a constant invariable manner. In England the wheat crop is cut in August, and presumably soon after is placed in the market. The maximum prevalence of enteric fever follows invariably in October-November. This of course may be only an unimportant coincidence. But when it is remembered that the two seasons of maximum prevalence of the. disease in India similarly follow the two harvests of bread stuffs, the sequence seems peculiar and worthy of
investigation.
Thus in India the first harvest (wheat, &c.) is saved in May or June, and one season of maximum prevalence of enteric follows in August. The second harvest (including some grain, the flour of which is used to adulterate wheaten flour) is saved in November or December, and is followed in the early part of the year by an increase of enteric fever which reaches its second maximum of prevalence in
April.
This seasonal increase of enteric cannot be due to seasonal influence directly, else why should it prevail during the cold of OctoberNovember in England, whilst in India it is during the heat of April and of August that it
prevails.
But if the flour of
new
wheat and other
grain
adulterate it, or the fermented bread made from it, is a possible source of infection, it is apparent how seasonal influence may indirect?used
to
ly explain the varying prevalence of enteric fever throughout the year both in England and
For it is just after the flour of each harvest is placed in the market that enteric fever becomes most prevalent, and it then declines until the following harvest is saved. in India.
[Oct.
1898.
Such flour may be bad or contain fungi that disease, such as pellagra, or be infected with the enteric bacillus from the hands through which it passes. If bread made from this flour is insufficiently baked, it forms an excellent medium for the growth and multiplication of the bacilli. Now there are many places in which flour may become infected with the bacillus of enteric fever,?in the cultivator's home, in the wheat stores, in the flour mills, in the bazaars, in the bakeries where men, not always too clean or perhaps recently from homes where relatives are suffering from the disease, are employed as sifters, kneaders, bakers, &c. It can be seen then if the flour, the water or the yeast used in making bread should become infected, how it becomes absolutely necessary that the baking should be perfect, that is, that the bread should be exposed to a temperature which will not merely arrest fermentation but will assuredly destroy any spores which ma}7 have found their wa}7 into it. In a subsequent paper I propose to invite attention to beer and tinned food as possible sources of infection. cause
(To
be
continued.)
