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poor persons when the conditions of life are such as to give opportunity for extension of the
disease. The early recognition of enteric fever, the use of the Widal test in all doubtful cases,
the isolation of the sufferer, and the employment of persons beyond middle life to attend upon the
sick, are all needed to limit such spread of the disease.
Special outbreaks of enteric fever are referred to in the annual reports relating to some other
districts. The medical officer of health of Islington reported on the prevalence of enteric fever in the
St. Mary's Workhouse school, in the boys' department of which 19 cases occurred in the past six
months, and in the girls' department, of which 21 cases occurred in July and August, 1899. In each
of the three preceding years 9, 1 and 4 cases had occurred respectively in the boys' department.
Dr. Harris, as the result of his investigation, came to the conclusion that the water in the cistern supplying
drinking water was liable to pollution in two ways : one from its direct connection with a water.
closet it supplied with water, the other from the tact that it was not aerially disconnected from the
water-closet chamber. The water supply was, moreover, he considers, elsewhere liable to pollution
by the steam from the boys' baths. Bacteriological examination of the water was made at the Jenner
Institute, and it was reported to be unfit for either drinking or washing purposes. Dr. Harris came
to the conclusion that pollution of the water caused the outbreak in the boys' school, and states that
there is little doubt that the girls were affected through the drains of the two departments being
connected with each other. Dr. Sedgwick Saunders gives account of an outbreak of enteric fever
in a retail drapery establishment in the City in which 620 persons were employed, 416 of whom slept
on the premises. On the 28th November, 1898, a case of this disease occurred on the premises, and
fifty days later, i.e., on the 15th January, a series of cases began, 53 persons being attacked between
that date and the 9th February. Dr. Saunders was unable to connect this outbreak with the water or
milk supply, but found certain defects in the drainage.
Dr. Moore came to the conclusion that three cases of enteric fever in Eltham were due to the
sewer with which the houses in which these persons dwelt being unventilated, and to the cellars of
these houses having drain inlets which were not disconnected from the sewer. Mr. Jackson states that
in three instances in Fulham "the disease was reported shortly after the basement of the houses had
been flooded with sewage, owing to the surcharging of the sewer."
In several reports it is stated that shell-fish had been eaten shortly before the beginning of
illness, thus in one instance, in Paddington, cockles had been previously eaten at Southend. In
Kensington " in several of the cases locally recorded, the sufferers had partaken of oysters, mussels,
&c., at seaside resorts, within such periods of time antecedent to date of illness as to suggest a
relationship of cause and effect." In Fulham, " In five cases the origin of the disease was ascribed
to shell-fish." In Marylebone, " in several cases there appeared to be good evidence that the
infection was taken in with such foods as oysters, mussels, or other shell-fish." In Stoke
Newington "two cases, doubtless, contracted the disease outside London; the disease appeared
to be due to the consumption of cockles in one case and to the consumption of oysters in
another case." In Holborn "in three cases there was good evidence that shell-fish might have caused
the disease." In Newington " in quite one-half of the cases notified within this period (middle of
September to middle of November) the friends of the patients attributed the disease to the eating of
shell-fish, presumably mussels. Certainly the eating of the mussels had taken place about eight or
ten days before the illness commenced or within the usual incubation period. The mussels were the
Dutch variety;' In Lambeth " in six cases there appears to have been a causal relationship between
the attacks and the previous ingestion (within the incubation period) of infected shell-fish, in three
cases oysters, in two cases mussels, and in one case cockles being the suspected medium." In Wandsworth
parish in five cases, "the patients had partaken of shell-fish shortly before." In Greenwich "it
was found that a great number of the cases had partaken of various sorts of shell-fish, such as oysters,
mussels and cockles. In Plumstead, " in two cases eating insufficiently-cooked mussels may have been
the cause, and in one case oysters."
In connection with the larger prevalence of enteric fever in 1899 must be mentioned the fact
that several of the medical officers of health have referred to delay in removal to hospital of persons
suffering from this disease. The medical officer of health of Paddington mentions that there was
occasional delay in the removal of persons ill of enteric fever during the late summer and early autumn.
In St. George-in-the-East there was in November " some little delay in effecting removal of cases."
In Poplar, "During the last quarter of the year, when typhoid fever prevailed, great difficulty was
experienced in obtaining the removal of patients, as many as fifteen being kept waiting at one time."
The employment of the Widal test may possibly have led to some increase in the number of
cases of enteric fever notified, several sanitary authorities undertaking to send material for examination
at their expense. In Fulham material from 17 cases was sent for examination, the result being
positive in 14 cases. In Chelsea material is sent to the Jenner Institute. In St. George, Hanoversquare,
material from 10 cases was sent to the Jenner Institute with positive results in three cases.
In St. Pancras material from 73 cases was sent for examination, the result being positive in 28,
negative in 42, and doubtful in 3 cases. In Islington material from 76 cases was sent to the Jenner
Institute, with positive results in 25 cases. In Stoke Newington material from 6 cases was examined,
the result being positive in 2 and negative in 4 cases. In St. Giles material from two cases was sent
for examination, with a negative result in each. In St. Martin-in-the-Fields material from one case
was sent to the laboratory of the Conjoint Board, with a negative result. In Limehouse materia
from three cases was sent to the bacteriologist of the London Hospital with a positive result in one
case. In Poplar material from 24 cases was sent to the Jenner Institute with a positive result in 18
cases. In Lambeth material from 81 cases was examined in the bacteriological laboratory of the
vestry with positive results in 40 cases. In Wandsworth material from 9 cases was sent to the
bacteriologist of the vestry with positive results in 4 cases. In Camberwell material from 8 cases
was sent to the bacteriologist of the Vestry with positive results in 4 cases. In Plumstead material
from 4 cases was sent to the Jenner Institute with positive results in 3 cases.