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There was diminished prevalence of enteric fever in 1903, the number of cases notified
being less than that in any year since the year 1889, when notification became obligatory, and in
»o far as deaths are concerned, the deaths in proportion to population were less than in any year
since 1869, when deaths from enteric fever were first separately classified. The diminished
prevalence in 1903 is well shown by the upper curve in diagram XVII., relating to notified cases,
from which it will be seen that the nearest approach to the conditions obtaining in 1903 since
notification has been obligatory occurred in the year 1892. So far, however, as the distribution of
cases throughout the year is concerned, diagram XVI. shows that this did not exhibit marked
deviation from the normal.
Among the articles of food which are mentioned as causes, or possible causes, of the cases
which occurred are shellfish, watercress, ice-creams, water, and milk.
The extent to which contaminated shellfish is productive of enteric fever in London cannot
be determined. In some of the instances recorded in the reports for 1903 and in preceding
reports there is evidence of shellfish being consumed by certain members of households and being
followed, at a time which corresponds with the incubation period of the disease, by the occurrence
of enteric fever among those who had partaken of the shellfish, and limited to people who had
so partaken. In other cases there is the additional evidence that the shellfish had been received
from a source suspected to be contaminated, for the reason that enteric fever had occurred
in other families who had received shellfish from that source. In other cases the evidence does
not amount to more than the fact that a particular person suffered from an attack of enteric
fever after eating shellfish some period before the attack which is within the limits of the
period of incubation. The number of cases in London actually due to the eating of infected shellfish
is necessarily problematical. This question was thus reported on by the Royal Commission on
Sewage Disposal in 1903—
After carefully considering the whole of the evidence on this point, we are satisfied that a considerable
number of cases of enteric fever and other illness are caused by the consumption of shellfish which
have been exposed to sewage contamination; but, in the present state of knowledge, we do not think it
possible to make an accurate numerical statement, at any rate, as regards the whole country.
In certain towns the subject has received much consideration, and the medical officers of health have
been at considerable trouble to collect all available data, but we doubt whether this practice has been
universally adopted throughout the country.
Moreover, an examination of the figures which have been placed before us as regards those towns
in which the subject has been most carefully studied shows that there may be occasional errors. Indeed,
the witnesses themselves recognised that absolutely accurate figures are not obtainable.
Isolated cases of enteric fever have been ascribed to shellfish where the patient had eaten shellfish
obtained from a contaminated source, at a period prior to the manifestation of the disease corresponding
with the incubation period, and no other source of infection was discovered.
We are far from denying that such isolated cases may have been due to contaminated shellfish,
but when we remember the numerous unexplained cases of enteric fever we feel that the possibility
of some of them being due to other causes cannot be altogether excluded.
Further, if the figures are accepted as correct in those cases in which careful records have been kept,
we have not the means of applying them to other towns. The extent of illness properly ascribed to
shellfish would depend partly on the proportion of the population who were consumers of shellfish, and
on the degree of contamination of the shellfish supplied to the particular town.
There can, however, be no doubt that the evil is sufficiently grave to demand a remedy.
The consumption of shellfish in connection with the occurrence of enteric fever is
mentioned in several of the annual reports, from which the following information is derived—
Paddington.—Probable cause of infection, oysters 4 cases, cockles 6 cases, mussels 2 cases,
winkles 1 case. Several cases of enteric fever believed to be due to eating polluted cockles occurred
in a family visiting Leigh-on-Sea. A group of cases occurred within a few days of each other in
two neighbouring streets; shellfish (cockles or mussels) had been eaten by the sufferers which had
been purchased from a hawker who admitted having procured them from Leigh-on-Sea.
Kensington.—In a few of the cases there was ground for suspicion that the illness had
been caused by the eating of shellfish—oysters in seven of the cases.
Fulham.—Three cases, probably due to shellfish.
Chelsea.— One case, probably due to consumption of cockles at Southend.
Westminster.—"In fifteen cases there appeared to be a direct connection with the eating of
shellfish (thirteen oysters, one mussels, one cockles)." Dr. Allan states that the occurrence
of a case of enteric fever in Westminster and several in other parts of London having possible
connection with the consumption of oysters in Westminster led him to communicate to the
Fishmongers' Company the names of the merchants supplying the Westminster tradespeople.
He was informed by the company "that they had watched certain beds at Emsworth, known
to be polluted, had seen oysters removed from them and traced them to Portsmouth and to
London (to a merchant supplying Westminster dealers). Those sent to London were sent under
a designation implying that they came from a pure source." The oysters were seized by the
Company. Dr. Allan adds that the Emsworth beds referred to adjoin those from which oysters
were taken which had given rise to a well-known outbreak of enteric fever in Winchester.
St. Pancras.—Dr. Sykes gives particulars of the attack of five members of a family by
enteric fever. The first person attacked was the father, who had a fortnight before eaten oysters.
Four children were subsequently attacked, the disease being communicated from person to
person.
Stoke Newington.—Dr. Kenwood states that the evidence in one instance pointed strongly
to the eating of oysters as a cause.
Holborn.—" In four instances there was strong evidence that the disease was caused by
eating shellfish, and in several others there was great probability that shellfish was the cause
of the disease."
Finsbury.—Dr. Newman mentions the eating of shellfish, oysters, cockles, etc., as a probable
cause of fourteen cases.
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