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59
It will be seen from the foregoing table that among the several metropolitan boroughs
the enteric fever death-rate was highest in St. Pancras and Shoreditch (0-1&) and lowest in
Fulham (0 06). The enteric fever death-rates in London in each of the four quarters of the
year 1902 were as follows—first quarter 0 09 ; second quarter 0-06; third quarter 0-15 ; and
fourth quarter 0-16 per 1,000 living.
The behaviour of enteric fever in London in 1902 was characterised by some prevalence,
abnormal in point of time, in the period 25th-30tli week, more especially marked in the 29th and
30th week (see diagram XY1II). This increase was not limited to any one locality, but was widely
distributed throughout London. Corresponding in point of time with this prevalence an outbreak
of enteric fever occurred in Southend, which was attributed by Dr. Nash, the medical officer of
health, to the consumption of contaminated shellfish. Such information as I was able to obtain from
London medical officers of health relating to cases of enteric fever in London associated with shellfish
eating did not explain the abnormal prevalence referred to, although its coincidence in point of
time with that of Southend is noteworthy. A further condition requiring consideration in
relation to the more marked prevalence in the 29th and 30th week, is the occurrence of floods
in the Thames in the 25th week, and in the Lee in the 24th and 25th week, which caused
in the filtered water of the several companies a notable increase in the organic matter beginning
either in the 25th or 20th weeks. This condition, however, could not have been concerned in
^causing the increase in the number of cases notified in the earlier weeks.
In discussing the causes of cases of enteric fever in London, the subject most frequently
referred to in the annual reports is that of infection from the consumption of shellfish. Large
quantities of shellfish, especially cockles, came to London from the neighbourhood of Southend,
and many London inhabitants visited Southend during the summer months, some limiting their
stay there to a single day, others residing there for longer periods, and many of these visitors
ate shellfish. There is no reason for doubting that many cases of enteric fever in London
were caused in this way, and it is highly probable that the consumption of shellfish from other
places has had a similar result. Many occurrences of enteric fever in this connection are
described in the annual reports of medical officers of health, of which the following deserve
especial reference. Thus Dr. Allan, the medical officer of health of Westminster, writes—
"Thirty persons are believed to have contracted the disease from eating shellfish;
twenty-two of these were persons in the Strand aud Covent-garden wards who had been
to Southend and Soutliwick, at one or other of which places they had eaten cockles or
mussels from sources known to have been sewage polluted. Another had eaten oysters
while yachting oft Poole, the oysters having been gathered by himself. Six others had
eaten shellfish from stalls in London, or on day trips to seaside places on dates which
would correspond with the periods of infection. In some instances the patients themselves
attributed the attack to such cause, as they had had some stomach or bowel trouble
soon after eating the shellfish."
With reference to the persons who went to Southend and South wick, the report of Dr. Allan
for the month of September contains the following statement—
" The marked decline which took place in enteric fever cases in London in August
was not maintained, the cases rising from 287 to 473, a figure in excess of that recorded
last year. In Westminster there have been no less than 26 cases, and the manner in
which a number of these contracted the disease suggests a possible explanation of the
increase in London generally. It will be observed that 14 of the cases were notified in the
wards of Covent-garden and Strand. Two other cases were notified at the end of the month
subsequent to the date of this report, and I am informed that a case has also occurred in
the Borough of Holborn, and is connected with this group; a fourth case of bowel complaint
in a brother of one of the above patients came to my knowledge, but the medical
men in attendance did not feel justified in notifying it as a case of typhoid fever."
" All those attacked were young persons, and on inquiry it was elicited that all of
them had been to Southend-on-Sea or Southwick (a small seaside village between
Brighton and Worthing) for a fortnight. Of these eighteen cases, seven had been to the
former place only, one to Southwick only, and ten to both places. All those who went
to Southend bought and ate cockles from itinerant vendors, and, with one exception (a
boy who went to Southend also), those who went to Southwick picked up mussels and ate
them, in some cases taking them to their lodgings to be cooked, but in a good many
instances the mussels were eaten raw. In the one exception, although the boy did not
eat mussels at Southwick, he had eaten cockles at Southend, and the interval between
so doing and falling ill was not too long to preclude the cockles as the source of the
disease, but he had been constantly in the water bathing or paddling at Southwick, and
had assisted other boys in collecting mussels. From inquiries I have made, there is no
doubt that infection through the medium of infected shellfish might be contracted at
both the places mentioned."
Dr. Bond, the medical officer of health of Holborn, states that in four cases "there was
strong evidence that the disease was caused by eating shellfish. One of them was a boy aged 13,
who had been at a school outing at Southwick for a fortnight, and had also visited Southend-onSea.
Of the boys who went to this outing eighteen were attacked with enteric fever, and all of
them had eaten cockles, or mussels, or both." Dr. Caldwell Smith found that of three cases of
enteric fever occurring in one house in Wandsworth, two were attacked simultaneously a fortnight
after eating cockles which had come from Leigh-on-Sea, the third case, who ate cockles a week
after the other two, being attacked a week later. A fourth case occurred a few days later in