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41
It will be seen from the foregoing table that among the several sanitary areas in the period 1903-7
the enteric fever death-rate was highest in Hackney (O.11), and lowest in Chelsea, Hampstead and
Lewisham (0.03) ; in the year 1908 Finsbury (0.12) had the highest enteric fever death-rate, while
in the City of London there were no deaths. The death-rates from enteric fever in London, in each of
the four quarters of the year 1908, were as follows : first quarter, 0.03 ; second quarter, 0.02 ; third
quarter, 0.04 ; and fourth quarter, 0.09, per 1,000 persons living.
Information is given in some of the reports concerning the numbers of persons attacked by
enteric fever in 1908 who had eaten shell-fish at a time consistent with the hypothesis that it was
the cause of illness. The districts referred to are Paddington, Fulham, Westminster, Hampstead,
Stoke Newington, Holborn, Finsbury, Poplar, Lambeth, Battersea, Wandsworth, Camberwell,
Greenwich and Woolwich. In these districts, after deduction of cases incorrectly diagnosed, some 454
cases of enteric fever are known to have occurred, and of these in 84 instances, or 18.5 per cent.
of the cases, shell-fish had been thus consumed :—
Shell-fish (not otherwise defined)
• • •
• ••
37
Oysters
• ••
• • •
• ••
21
Mussels
• ••
• • •
•••
20
Winkles
• ••
• • •
• ••
4
Whelks
•••
• • •
•••
2
84
There is no information as to whether this proportion is in excess of the proportion of the population
unattacked by enteric fever, which would be found on enquiry to have eaten shell-fish. In only one
report is mention made of fried fish being eaten antecedent to an attack of enteric fever, and in the
district to which the report relates there were only three such cases. Inasmuch as the London
poor are large consumers of fried fish, it is not unlikely that absence of record rather than absence of
occurrence may have been responsible for the conspicuously small number mentioned. Again,
watercress, which has been thought by some to be responsible for occurrences of enteric fever, is mentioned
in three reports in relation to seven total cases in these districts, and ice cream, clearly shown
by Dr. George Turner to have caused a considerable outbreak of enteric fever in Deptford in 1892,
is only mentioned in one report, and then in relation to four cases. It is probable that absence of
record again plays a part here although there has undoubtedly been improvement in the conditions
under which ice cream is made, effected by the administration of the provisions of the Council's
General Powers Act of 1902 relating to the manufacture and sale of ice cream in London.
A notable feature in the behaviour of enteric fever in London in recent years, has been the
manifestation of localised prevalences occurring in poor populations and lasting often for a considerable
number of weeks. There were two such prevalences in 1908, one in Bethnal Green the
other in Shoreditch. The Bethnal Green prevalence occurred in the months of September and
October. The cases in the Shoreditch prevalence extended over a longer period, which included those
months, during which numerous cases occurred. Dr. Hamer was given by Dr. Bate the opportunity
of investigating the Bethnal Green outbreak, and in Appendix I. will be found a report from
him on this subject. In this report he also discusses the Shoreditch outbreak, the particulars of which
were supplied to him by Dr. Bryett. It would appear that both Dr. Bate and Dr. Bryett consider
the prevalences in their respective districts to be due in the main, if not altogether, to the influence
of infection from person to person, while Dr. Hamer does not regard the observed facts as explicable
on this basis, and sees reason for thinking that they must have been in great measure caused by
infected food supply. In both districts the locality implicated was occupied by very poor persons
living under the conditions which are usually observed in the homes of people of this class. It
was found in Shoreditch, that in numerous instances there were multiple attacks in houses, i.e.,
two or three, or even more cases occurred in some of the houses, while in others only one
case occurred.
A point of considerable interest in the investigation of such occurrences is the extent to which
enteric fever may be communicated from person to person. The view that enteric fever will spread
by case-to-case infection is generally accepted, but the question needs careful consideration whether
this can occur on the scale shown by the Shoreditch figures, if we are to regard the secondary cases
occurring in houses as due entirely to infection from the first case, and, indeed, the so-called
primary cases as also due to personal infection. The conditions which exist in the homes of persons
of the class who suffered in Shoreditch are precisely those which would give opportunity for infection
from person to person. On the other hand, persons attacked by enteric fever are removed from
these houses as soon as the disease is recognised, and therefore are not exposing others to infection
during the whole period of their illness. Mild and unrecognised cases no doubt remain, and these
have to be thought of in estimating the amount of opportunity for case-to-case infection.
In attempting to determine whether multiple cases occurring in houses are due to infection introduced
into the house by an article of food, or to personal infection, or to both causes, the difficulty
presents itself that the incubation period of the disease is variable, and often the beginnings of the
illness are so indefinite in their manifestation that it is impossible to determine the date of attack
with any precision. Hence an infected article of food supplied on a particular day may give rise