Dr. H. Timbrell Bulstrode’s Report to the Local Government Board upon alleged Oyster-borne Enteric Fever and other Illness following the Mayoral Banquets at Winchester and Southampton, and upon Enteric Fever occurring simultaneously elsewhere, and also ascribed to Oysters. Ay. H. PoM^EK, Medical Officer, 14th May, 1903. On December 16th, 1902, a telegram was received from Dr, Lockhart Stephens, Medical Officer of Health of the AAffirblingtoii Urban District in Hampshire, stating that there were several cases of enteric fever at the town of Emsworth, and that, from information derived from Winchester and Southampton, Dr, Stephens had reason to believe that specifically infected 0}^sters were being imported into these towns from Emsworth, and were causing enteric fever therein. The Board also received about this time information from other sources to the effect that cases of enteric fever had occurred among guests at the mayoral banquets at the two towns here in question. It was stated, too, in the public press that cases of enteric fever had occurred at Portsmouth which had been attributed by the medical officer of health to the consumption of oysters, and on December 17th a telegram was received from the Sanitary Committee of the Portsmouth Corporation drawing the attention of the Board to the outbreak referred to. In consequence of this information I was instructed by the Board to proceed to the several places mentioned to investigate the circumstances, and to report thereon. I now give an account of the facts which I elicited at each place, and of the investigations subsequently made relative thereto. THE MAYORAL BANQUET AT WINCHESTER. On November 10th, 1902, there took place at the (Tiiildhall, Winchester, a dinner to the ex-mayor, 134 guests being present. Of these 134 guests, nine had, at the date of my visit on December 17th, developed enteric fever, as also had one of the waiters who officiated at the banquet, and who partook of a certain item in the menu. Of these 10 persons, two,* including the waiter, were already dead. I gathered, too, from the Mayor and from members and officials of the Corporation who were present at the Guildhall at my preliminary conference, that, in addition to the 10 cases of enteric fever, there had been, among persons present at the banquet, numerous cases of gastro-enteritis of varying degrees of severity. The cause of these cases of illness had not then been definitely determined, although suspicion had, it appears, fallen upon both the soup and the oysters consumed at the banquet, while, by some, the mischief was ascribed to other articles on the menu. * Two more died subsequently, making four fatal cases in all. — H. T. B. LONDON: PRINTED FOR HIS MAJESTY’S STATIONERY OFFICE, By darling & SON, Ltd., 34-40, Bacon Street, E. And to be purchased, eithei' directly or through any Bookseller, from EYRE SPOTTISWOODE, East Harding Street, Fleet Street, E.C., or OLIVER & BOY D, Edinburgh ; or E. PONSONBY, 116, Graeton Street, Dublin. r.H)3. Price, One S/ti/linq. No. 185. 1000 Wt 23606 6/03 D&S 19 13593 2 It appeared to me desirable that an exhaustive iuquhy should he made with the object of ascertaining, if possible, what article or articles of diet might have been responsible for the outbreak. I therefore suggested to the mayor and the medical officer of health that a copy of the menu in the form shown in the appendix (pages 20 and 21) should be forwarded to each of the guests, and that they should be asked to state of what articles of the menu they partook, whether they suffered any indisposition or illness shortly after the banquet and, if so, the nature of such attack ; and also whether they ascribed it to the banquet. My suggestion was at once adopted, and after a considerable lapse of time, caused mainly by the serious illness of several of the guests, the informa- tion was procured, which is tabulated in Appendix No. 1 (pages 22-28). I may add that I also visited, in company with the medical officer of health of Winchester, several of the cases of illness other than enteric fever, and that I called upon each of the medical practitioners who had been in attendance upon the enteric fever cases. In the table in the appendix the articles partaken of by each guest at the banquet are tabulated, the cases of illness being printed in italic, and the cases of enteric fever being differentiated by means of black type. An asterisk is placed against the initials of those attacked with gastro- enteritis and a f against the initials of those who suffered from enteric fever. I would draw special attention to these tables as they serve to show at a glance the very considerable amount of illness following the banquet. I have made an analysis of this table, and I herewith arrange the results in tabular form. In enumerating the cases, those articles against wdiich a ? was placed by the guest have been omitted, such units having been reckoned neither among the consumers or non-consumers of the articles in question. This appeared to me, after consideration, to be the fairest manner of dealing with the doubtful factors. Out of the total 134 guests no less than 62, or 46'3 per cent., were attacked with illness of some kind or other. Of the 63 persons (inclusive of the waiter) who became ill — 2 did not take oysters. At least 23 99 99 clear soup. 55 40 99 99 thick „ 55 38 99 99 smelts. 23 99 99 turbot and lobster sauce. 5? 15 99 99 sweetbread and spinach. ?? 51 99 99 kidneys and mushrooms. ?? 50 99 99 boiled mutton. 45 99 9' roast „ J? 50 99 99 roast beef. 37 99 99 venison. 44 99 99 red currant jelly. ?? 56 99 99 capons. n 50 99 99 ham. 95 54 99 99 tongue. 59 43 •9 99 turkey. 99 27 99 99 pheasant. 99 50 99 99 partridge. 99 48 99 99 Sir Watkin Wynn pudding 5 5 52 9^ 99 Charlotte russe. 99 ^6 99 99 liqueur jellies. 5^ 54 99 99 caramel cream. 99 57 99 99 maraschino cream. 99 47 99 99 meringue. 99 19 99 99 ice. 59 32 99 99 cheese. 99 46 99 99 salad (celery). 99 45 99 99 aerated water. The enteric fever cases considered tever — All the 10 took oy??ters. least .'i did not take ?? 4 55 55 6 55 55 r 2 55 5' )? 1 55 51 57 6 ■5 55 r- 55 0 55 5' 55 ml 1 7 55 55 55 55 55 5 55 55 .0 55 55 ^5 7 55 55 b 55 5' 7 55 5 5 5' h 55 55 1 55 55 •5 5 55 55 55 •T) 55 55 55 5 /T 55 55 55 1 55 55 55 7 55 55 55 8 55 55 55 5 55 55 55 8 55 55 55 3 1 5 55 55 5 55 55 55 3 55 55 separately. — Of the 10 cases of enteric clear soup, thick ,, smelts, turbot, svreetbread. kidneys and mushrooms, boiled mutton, roast ,, , , beef, venison, currant jelly. cap(jns. ham. tongue, turkey, pheasant, partridge. Watkin Wynn pudding. Charlotte russe. liqueur jellies, caramel cream, maraschino cream, meringue, ice. cheese. salad. aerated water. The advantage of the scheme thus adopted is that, so far as enteric fever is concerned, it is permissible to exclude every article on the menu with the exception of oysters, so that from this point of view it is unnecessary to enter at any length into the composition, or the source, of any other articles in the menu. It may, however, be stated that, with regard to illness generally, the matter has been thoroughly gone into, and in the appendix (page 29) will be found the precise composition and the source of each article which went to make up the menu. With respect to the turtle soup, which is one of the items to which suspi- cion had locally attached as causative of indisposition if not of actual illness, it is clear, seeing that at least 23 of those who were taken ill did not partake thereof, that no reasonable suspicion can attach to it. It was alleged that the “ stock ” from which the soup was made was prepared in copper vessels which had not been recently tinned, and that directly after the banquet these same vessels were sent by the caterer to be re-tinned. As the figures already given will, I think, sutfice to show that neither of the soups was the source of miscliief, I do not propose to discuss the matter further, nor do I propose to deal with each article of the menu separately. Such a discussion, in face of the evidence above set forth, is superfluous. Additional data. — It occurred to me in the first instance that enquiries relative to the waiters and other attendants who were present at the banquet should furnish evidence which might be put to use in tracing out the cause of illness, and, consequently, forms of enquiry were sent to each of the attendants. Forty-two returns were received in this connection, e.xclusive of the waiter who contracted enteric fever and died, and who is included in the list published in the appendix, but it has to be observed that the waiters partook of only a few of the articles which formed part of the general menu. i 2 13593 4 Among these 42 attendants only eight took oysters, and none of these suffered from enteric fever. But if for the moment, the dead Avaiter be included, it is found that there occurred one case of enteric fever among nine oyster eaters, which is about tlie same percentage incidence as upon oyster-eating guests, he., nine cases among 11 o oyster-eaters. In the matter of illness other than enteric fever there was but one case of indisposition, and that was a waiter who placed a ? against oysters, and tvho tvas “ taken A^ery sick Avith dysentery for the next two days,” and who continued more or less unwell for a wmek afteinvards. It is clear, therefore, seeing that among 43 waiters there was but one case of enteric fever and one case of illness, that among these attendants some factor was absent which was operative among the guests. The ladies in the gallery. — A few ladies Avere present towards the end of the banquet, and they were furnished with light refreshments by the caterer. These refreshments consisted of sandwiches, bread and butter, cakes, coffee, and strawberry ice cream. The constitution of the ice cream was the same as that of those used for the guests, and hence it seemed that the information under this heading might proA^'e of use. These ladies AA^ere kind enough to fill up the forms which were sent to them, and from these it appears that none of them suffered any indisposition. The observed nature of illness suffered by partakers of the banquet. — A study ■of the notes on the table in the appendix (pages 22-28) will shoAA^ that persons who suffered from illness following the banquet may be divided into four groups : — (a) Those who suffered from gastric pain, Ammiting, and diarrhoea a few hours after the banquet. (h) Those who suffered from an attack of gastro- enteritis three or four . days after the banquet. (c) Those who suffered from enteric fever. {d) Those who suffered from \mmiting and diarrhoea shortly after the banquet, and also, later, from enteric fever. How far was illness.^ enteric fever or other., occurring in Winchester at this particular time referable directly or indirectly to the banquet I — Although it may seem somewhat superfluous to discuss this question it is desirable that the connection of the banquet with the illness shall be reasonably established before proceeding further. Now the banquet, or rather the presence of the guests at the Guildhall on November 10th, was, as far as could be ascertained, the only factor common to the lives of all those who were subsequently attacked. It was, however, necessary before the connection of illness with the banquet could be logically arriA^ed at to enquire whether there had been after the banquet any general preA^alence of enteric fever and gastro-enteritis among persons who had not been present at the dinner. But as far as could be ascertained all the cases of enteric fever and gastro-enteritis which occurred in Winchester immediately subsequent to the banquet were among persons who weie present at the banquet ; indeed it will be seen by the next section that there were but A^ery few cases of enteric fever in Winchester during the last six months of 1902. The prevalence of enteric fever hi Winchester. — It is of particular importance to ascertain how many persons there were suffering from enteric fcA^'er in W^inchester at or about th'e time of the banquet, but Avho were not present at such banquet. Dr. Langdon has been good enough to furnish me Avith a list of the cases notified in Winchester during the last six months of 1902. From this list it appears that, excluding the ten cases among persons who attended the banquet, there were only seven cases notified as enteric fever in Winchester since the end of June, and that of these seven cases four were in all probability imported, while one person was subsequently found not to have had enteric fever. Of these seven persons, therefore, probably only two contracted their disease in Winchester. The cases of enteric fever notified in AVinchester during the last few ^^ears have been as follows : — 1898 • • f 3 cases. 1899 • • • 3 „ 1900 • • • 2 „ 1901 • • • 1902 • . . 19 ,, (10 in connection with banquet) The sanitary condition of the houses invaded by enteric fever. — As a matter of routine the sanitary condition of the houses in which the enteric fever cases occurred was examined by Mr. John Lord, the Winchester Inspector of Nuisances. He reported that in seven of these houses the condition was “ satis- factory.” In three there were sanitary defects, and tliere were also sanitary defects in the business premises of one of the patients whose private house was in a “satisfactory ” condition. The milh supply in relation to the enteric fever cases. — The ten invaded households were supplied with milk from six different sources so that there was obviously no sufficient ground for attaching suspicion to the milk supply. The sanitary condition of the Guildhall. — It might be contended that the outbreak was due to defective drainage arrangements in the Guildhall itself. I therefore examined the plans of the drainage, and, in company with the Medical Officer of Health and Inspector of Nuisances, went over the building. The drainage is not modern, and there were certain defects to which I called attention and which will, I believe, be remedied. But these defects would not be at all likely to have caused the remarkable and unique explosion of illness with which I am now dealing. Moreover, had the sanitary condition of the building been responsible for the illness which is in question, there would be difficulty in explaining why such defects exercised their influence almost without exception upon the consumers of one article of diet, or why the ladies in the gallery, and the waiters, were practically exempt from attack, and why, further, such an explosion should not have taken place in connection with other aggregations of persons in the same hall. The oysters consumed at the banquet. — The caterer to the banquet informed me that the oysters consumed were procured through a local fishmonger, and that they were neither handled by him nor were they sent in transit to his place of business. Intermediate handling of them by the caterer might, had it occurred, possibly have been a point of considerable importance, as will be seen later. The fishmonger from whom the oysters were procured by the caterer stated that he in turn obtained them from an oyster merchant at Emsworth on November lOth, the day of the banquet. These oysters were delivered to the fishmonger’s shop in Winchester, “given a drink” of salt and water, opened at the shop,. brought down to the banquet on their flat shells on a tray, and forthwith spread out by the waiters on the plates,, three oysters being placed before each guest. The oysters were what are known in the trade as “ Best French,” /.e., they were oysters imported into this country from France, to be laid down or stored in our waters. In this instance the oysters had, I ascertained subsequently, come originally from a source other than Emsworth, and they had been stored in the ponds at Emsworth for only a few days. Although it appears from the returns sent in that one or two of the guests did not altogether approve the oysters placed before them, a scrutiny of the table in the appendix (pages 22-28) will serve to show that the oysters were more generally patronised than any other article on the menu. But certain of the guests only ate two oysters, and one of those who subsequently developed a fatal attack of enteric fever only took one oyster. Another enteric fever patient remarked at the time of the dinner that he did not like the oysters, and yet another that “ one of the oysters was bad.” 6 A case of enteric fever in the caterer's family. — In order that all the evidence bearing upon the case may be fairly set forth, it is necessary to refer to the fact that a son of the caterer was attacked with illness about a week after returning from Cowes on August 12th, and that he was found in the first week in September to be suffering from enteric fever, which it is believed that he contracted from eating oysters at Cowes. The patient was isolated on the top floor of the caterer’s private residence, a large modern house in the suburbs of Winchester. He was nursed by two trained nurses, and after the termination of the illness his room, bedding, &c., were disinfected. Such disinfection was carried out on November 1st, and the evidence points to the fact that his case had no causal relation to the outbreak here under consideration. I make mention of it, however, to show that the question of the possible infection of the oysters after they left the ponds has not been lost sight of. As I have already pointed out, the oysters were not handled by the caterer or by any of his family, nor did they even go to the Guildhall via the caterer’s place of business. Summary as regards Winchester. — The foregoing facts combine to form a very strong presumption that the illness here in question was caused by the banquet, and that the only item taken at the banquet capable of affording an adequate explanation of the attacks of illness which followed was the oysters. The fact that two* of the guests who did not take oysters were attacked with illness after the Imnquet by no means suffices to negative the evidence tending to incriminate the oysters. As regards any feast of the magnitude of the Winchester banquet it might reasonably be expected that some of the guests would suffer indisposition afterwards ; . indeed, it may be regarded as probable that a few of those who were ill, but who also took oysters, may in point of fact owe their illness to something other than the oysters. f THE MAYORAL BANQUET AT SOUTHAMTON. /V. The mayoral banquet at Southampton took place at the South Western Hotel, Southampton, on Nov. 10th, 1902, and there were in all 132 guests. Out of this number ten subsequently developed enteric fever, as also did one of the attendants at the hotel who had partaken of certain articles on the menu. In addition to these eleven cases of enteric fever there were a number of cases of gastro-enteritis. At the date of my visit to Southampton^ the enteric fever in question had already been ascribed to the oysters : the evidence indeed accumulated by Dr. Lauder, the medical officer of health, had appeared to him so strong that he had reported the matter to the Local Government Board, and was about to issue a notice warning persons against the danger of consuming oysters from the locality where they had been derived. I deemed it, however, expedient that the problem at Southampton should be attacked on the same lines as that at Winchester, and Dr. Lauder was good enough at once to fall in with my suggestion that a circular in the same sense as that used at ATinchester should be forthwith despatched to each of the guests. Although a large number of the returns were sent back to the medical officer of health with promptitude, tabulated in his office, and forwarded , to me, complete information was only in our hands at the end of January. These Southampton returns, which have been arranged in tabular form in Appendix No. 2, suggest that the mischief which followed the Southampton * Mr C was quite well after the dinner on November 10th, but on November 12th and 13th he suffered from abdominal pain. He had no nausea. For a fortnight prior to the banquet he had suffered from constipation, and shortly before the dinner he. had taken an aperient. Mr. C would not have attributed his illness to^ the banquet had there not been a rumour that several cases of illness had been caused by it. Mr F was ) Those whose illness did not take place until three to five days after- wards. (c) Those who suffered from enteric fever. {d) Those who suffered from illness a few hours after the banquet, and who, in addition, developed enteric fever later on. Alike, therefore, at Winchester and Southampton there appear to have been poisons of an analogous nature at work ; and the results obtained may have been brought about by — (a) A toxin already formed in food, and capable of producing toxic symptoms within a few hours, or, conceivably some rapidly acting bacteria capable of producing the same manifestations. (h) An infectioii of the food by bacteria requiring some three or four days to produce in the human body sufficient bye-products to bring about toxic symptoms. (c) Presence in food of the specific bacteria of enteric fever requiring one, two, or three weeks, or thereabouts, to give rise to symptoms of enteric fever. (6?) A mixed infection of the food by a ready-made toxin, or possibly some rapidly acting bacteria, and by enteric fever bacteria, the toxin or bacteria manifesting their effects on the consumer in the one case in a few hours, in the other after a considerable period of incubation had elapsed. How jar teas the illness at Southampton referable to the banquet. — It is possible on the facts recorded to eliminate from consideration the vast majority of the articles consumed at the Southampton banquet, and reasonable suspicion can alone attach to the oysters and the turtle soup. Before, however, discussing these articles of diet, it may be mentioned that, locally, some suspicion was in the first instance attached to the beans, which, it was alleged, were tinned. But a reference to the table will show that at least 28 persons of the 55 who were ill did not partake of beans. Moreover, the enquiries which were made satisfied both Dr. Lauder and myself that the beans were not tinned, but that they were, on the contrary, fresh hot-house beans, for which a high price had been paid. Passing now to the oysters and the turtle soup. llie oysters. — It will be seen by this table that with one exception all those who werd attacked with illness of one or another description took oysters, and that the one guest wlio was ill, but who took no oysters, suffered from slight abdominal pain.” It may, I suggest, be fairly said that all attacked with illness took oysters, and this article of food was the only one common to all those so attacked. . The turtle soup. — Of the 55 persons who were taken ill at least six did not partake of turtle souj), a fact which in itself goes far to negative belief that the illness was in any degree due to this article. In the appendix will be found a list of the articles out of which the “ stock,” which formed the basis of the turtle soup, Avas made. The process of preparing the “ stock ” renders it necessary that the compound shall be actually boiled on more than one occasion, and this fact renders it improbable that the soup was the cause at any rate of the enteric fever or other bacterial infection. As to illness of other sorts the tinned turtle used in this instance was of West Indian origin and prepared by a French firm, and the specimens of this which I was shown were quite “fresh ” and the tins not “ blown.” The rhef io whom I spoke upon the subject seemed fully alive to the danger of using a “ blown ” tin, i.e., a tin the ends of which are distended by gas. There is e^mry probability that the turtle used had been properly sterilised. Moreover, there was no complaint as to the quality of the soup. Nevertheless, it is theoretically possible that one of the ingredients of the soup may have contained ready-formed toxins which the boiling was insufficient to destroy ; indeed, but little is known as to the effect of heat upon toxins. But, even if this were so, a theory of this nature, improbable as it is, would not account for the bacterial infection which, in my view, was responsible both for the later developing gastro-enteritis and for the enteric fever. The oysters supijlied to the Southampton hamjuet. — The oysters consumed at this banquet were obtained by the caterer from a firm of local fishmongers who, in turn, procured them from the same firm at Emsworth as that which supplied the A¥inchester banquet. On November 10th, 1,000 oysters were sent from Emsworth to the fish- monger who supplied the Southampton banquet. These oysters, like those consumed at Winchester, were of French origin, and they had, so I was informed, been relaid on certain English gi'ounds. They had been sent from those grounds to Emsworth, and stored in the ponds there until wanted. The oysters in question are knowm in the trade as “ French, 1st quality,” and they were described on the menu as Huitres de Whitstable.” These oysters arrived at Southampton from Emsworth at about three o’clock on the afternoon of Monday, November 10th, and they were sent in the same package as that in which they arrived to the South Western Hotel, where they were opened, the “ lift man ” who was subsequently attacked with enteric fever assisting in the process. The oysters were opened in the basement of the hotel, and they were sent up in the lift to the small kitchen which adjoins the hall in which the banquet was held. About 600 oysters were opened, and the remainder were returned to the fishmonger who supplied them. It will thus be seen that the oysters which were supplied to the Southampton guests were derived from practically the same source as were those which were furnished to the guests at Winchester. The enteric fever cases. — Of the eleven persons, including the “ lift-man,” who attended the banquet and who were subsequently attacked with enteric fever, eight were inhabitants of Southampton, and their illness was in due course notified to the medical officer of health. One of the three remaining cases lived at Cirencester, in Gloucestershire, another at Woolston, and another at Swathling. In fact there was an approach here to the phenomena observed in the well-known outbreak of enteric fever which occurred at the Wesleyan College, Connecticut, of which a full account is given in the supplement in continuation of the Report of the Medical Officer of the Local Government Board.* Other enteric fever cases which occurred in Southampton about the same date among persons uTo icere not present at the banquet. — Besides the eleven cases which attended the banquet, there were other cases which were notified to the medical officer of health between December 8th and 15th, and the following is a summary given me by Dr. Lauder of such cases : — Date of Notification. Initials. Age. When taken ill. 1 December 8 W. L. ... 20 December 1 Ate Emswoi’th oysters Novem- ber 28th at a shop. 12 F. A. F. ... 23 „ 2 Fishmonger. 91 16 S. W. ... 44 7 Ate Emsworth oysters in a shop November 17th. 99 9 M. B. ,8 November 28 Ate Emsworth oysters from time to time. 91 9 A. W. ... 4 „ 29 99 9 G. C. 9 - Admitted from outside borough. 99 9 K. G. 22 December 4 Nursing patients with enteric fever for considerable time before and up to her attack. 99 11 E. M. ... 19 November 27 Ate Emsworth oysters Novem- ber 12th. *“On Oyster Culture in Relation to Disease.” Supplement in continuation of the Report of the Medical Officer for 1894-5. Twenty-fourth Annual Report of the Local Government Board. 13593 B 10 Writing to me on December 2 4th, Dr. Lauder mentions that another case of enteric fever had occurred in Southampton in a person who had eaten Emsworth oysters. Negative evidence as regards oysters f urnished hy the Southampton banquet. — It will have been noticed that some 400 oysters were returned from the South Western Hotel to the fishmongers who supplied them. An endeavour was made by Dr. Lauder to ascertain what became of these oysters, but as it was only after December 18th, i.e., live Aveeks subsequent to the banquet, that the fact of the return of so many oysters became appreciated, there w^as difficulty in following up the matter. Dr. Lauder was informed of six places to which these oysters were said to have been sent, and enquiries were made wherever possible. Ho information was, however, procurable, save in respect of a certain banquet which took place at Southampton, on the loth of November, and which was said to have been supplied with some of the oysters which were left over from the mayoral banquet. Enquiries were made of the guests present, and of the 32 who replied 18 had partaken of oysters. Of these — One replied : — In bed 15tli December. Pain in small of back, T. 102°, and shivering, but was out next day. Illness not attributed to banquet. Another replied ; — Pain across shoulders, chest, and stomach ; lassitude. Illness not attributed to banquet. A third, who did not state whether he took oysters, replied : — On 19th and 20th November had severe headache with feverish symptoms. Not definitely ascribed to banquet. No great importance is to be attached to this negative evidence, even assuming that the oysters in question to have been part of the batch of 1 ,000 supplied to the mayor’s banquet (and it will be seen later how great was the difficulty in obtaining reliable information). They had been kept for three additional days, and possibly during that time the enteric fever bacillus, assuming it to have been present in some of them, may have perished. As regards other forms of illness such as gastro-enteritis, it is to be observed that there are no means available for determining its prevalence ; in only a few cases would medical assistance be sought, and it is improbable that such attacks would be brought to the notice of the medical officer of health. The efforts therefore, which were made after December 18th to determine wdiether or not harm had resulted from the consumption of the 400 oysters remaining over from the mayoral banquet on November 10th w^ere unsuccessful. The sanitary condition of the South Western Hotel. — Shortly after the banquet Dr. Lauder turned his attention to this matter, and as a result of his investigations he reported to the sanitary committee that there was nothing in the sanitary condition of^ the hotel which would be likely to account for the outbreak. I subsequently inspected the drainage myself, and I am quite in accord with Dr. Lauder on this point. The sanitary condition of the invaded houses. — The sanitary condition of these premises has been carefully gone into by Dr. Lauder, and he has kindly furnished me with the following facts : — Initials. Premises. Remarks. G. H Carlton Crescent Drains tested ; no defects found. T. J Bargate Street ... Do. do. W. H. R Westwood Road Do. do. J. F Polygon Drains tested ; found. no internal defects G. F Belmont Road Drains tested ; no defects found. J. H “ Holly holm ” Do. do. J. M Belmont Road Do. do. 11 The milk supjjly of the invaded houses. — The source from which the milk wiis supplied was in eadi case investig'ated, and the results showed that there was no common source of supply ; indeed nearly every house vras supplied from a different source. The behaviour of enteric fever in Southampton apart from the particular series of cases. — As a general rule enteric fever in Southampton is confiiied to the poorer portions of the town, but in the series of cases here under considera- tion the incidence has been on portions of the borough in whiclTj^ases of enteric fever are of rare occurrence. As affording some indication of the prevalence of enteric fever in Southampton, I submit herewith the notification figures for that disease for each of the five last years, as also the figures for the month of December in the same years. Enteric Fever. Year. Total Notifications. Notifications for December. 1898 154 10 1899 173 3 1900 73 4 1901 106 3 1902 123 18 Summary of the Southampton outbreak. — After the banquet on November 10th there occurred 11 cases of enteric fever and 44 cases of gastro -enteritis. The only circumstances common to the lives of those thus attacked was the mayoral banquet f on November 10th, a date which would be consistent with enteric fever infection having been contracted at such banquet. On this occasion the only article of diet common to the sufferers — apart from a single and doubtful case which may be disregarded in this connection — was oysters which had been procured from the same sources and at the same date as those that were consumed at the Winchester banquet. PORTSMOUTH. Cases of enteric fever in Portsmouth ascribed by the medical ofirer of health to the consiirnpjtion of oysters from Emsworth. — In consequence of a telegram which had been received by the Local Government Board from the Town Council of Portsmouth relative to an outbreak of oyster-borne enteric fever in that town, 1 visited Portsmouth on December 18th, and conferred with Alderman Emanuel, the Chairman of the Sanitary Committee, and with Dr. Mearns Fraser, the Medical Officer of Health. I then learned that there had been 22* cases of enteric fever notified in the liorough between November 5th and December 16th, and that all these cases had been attributed by Dr. Fraser to the consumption of oysters procured from Emsworth. The cases, generally speaking, belonged to a class of persons in comfortable circumstances, although some of the patients were described as “ poor.” Dr. Fi •aser informed me that he had excluded other likely causes of enteric fever, and that oysters appeared to him to be the most |>robable source of infection. There had, it appears, been no cases of illness following the mayoral banquet on November 10th, although oysters had formed part of the menu. * B 2 13593 Three other cases occurred subsequently, making 25 in all. V2 As it was a matter of interest to determine the source of the oysters in this instance, the oyster merchant who supplied the oysters was sent for to the town hall. He stated that the oysters in question were procured direct from Whitstable. According to the fishmonger, the oysters came down from London on November Stir and were taken unopened to the banquet. There were 120 guests present at this mayoral banquet, and at a more recent banquet to Lord Roberts there were 280 guests present. He supplied the oysters on eacli occasion, and in each instance the oysters were supplied direct from Whitstable. I have, however, reason to believe that, although the oysters referred to above were procured from Whitstable, they were in each instance stored for a short period in the Emswortli ponds. I have had considerable difficulty in ascertaining the facts in this case, but I eventually saw the entries in the books of the Emsworth oyster merchant who supplied the oysters, and he informed me that, as a matter of fact, the oysters in each instance had been deposited in the Emsworth ponds. This illustrates the manner in which a grave injustice may be done to certain oyster layings and beds, and it accentuates the importance of the greatest care being exercised in working out outbreaks of this nature. My other public duties have not allowed me to enquire personally into the outbreak of oyster-borne enteric fever in Portsmouth, bu,t Dr. Fraser has furnished me with the interesting report which he made uj)on the subject to the Sanitary Committee of the Portsmouth Corporation, which report is repro- duced in Appendix No. 3. Briefly it is to the following effect : — Between December fth and 14th the medical officer of health had his attention arrested by the unusual number of notifications of enteric fever, and by the fact that the cases in question inhabited a portion of the borough as a rule but slightly invaded by the disease. Upon detailed empiiry the medical officer of health found that the only factor common to all the cases was the consum|)tion of oysters, and it further transpired that these oysters w^ere taken at a date which was consistent with their having been the cause of the illness. These oysters were procured from Emsworth, a place at which. Dr. Fraser had reason to know, the o}^sters were liable to be polluted by sewage. None of the usual vehicles of infection, such as water, milk or other articles of food, were competent to explain the outbreak, nor Avere there such general drainage defects in conneation with the invaded houses that the prevalence of the disease could be reasonably attributed to this cause. Moreover, personal infection was apparently almost imperative in the series under consideration. Finally, Dr. Fraser was able to ascertain that 18 out of the 25 cases which were notified betAveen December 4th and '21st had consumed oysters between November 10th and 2bth, i.e., at a date Avhen, as Avill be seen shortly, the oysters had opportunity of becoming specifically })olluted in the Emsworth ponds. PLACES OTHER THAN WINCHESTER, SOUTHAMPTON, AND PORTSMOUTH, AT WHICH OCCURRED CASES OF ENTERIC FEVER IN NOVEMBER AND DECEMBER, AND SOME OF WHIICH WERE ATTRIBUTED TO THE CONSUMPTION OF OYSTERS FROM EMSWORTH. Seeing that EmsAvorth is an important centre for the distribution of oysters to many parts of England, it seemed not improbable that an inquiry at some of the places to which oysters had been sent on or abput the date at Avhich the oysters \\'ere furnished to the Wincliester and Southampton banquets might Yfford some interesting information. i, therefore, abstracted from tlie books of the oyster mercliants who supplied the oysters to the banquets in question the names of certain of ihe places to Avhich oysters had been sent on or about ' NoA^ember 10 th, and I caused to be sent to the medical officer of health of each place a letter inquiring into ])re\valence of fever and other gastro-enteric illness subsequent to that date. 13 I furnish in Appendix No. 3 my letter and a1:>stracts of the answers, in a positive sense, arranging these replies in the order in which they reached me, and I would here express my thanks to Dr. Arthur Mitchell, Dr. Caldwell Smith, Dr. W. G. Willoughby, Dr. Arthur Newsholme, and Dr. A. Grilfiths, for their kind co-operation. I have omitted from these replies any matter ol a confidential nature. The majority of the replies 'which I received Avere of a negative character. No cases of enteric fever had in the localities in rpiestion been either traced to or been surmised to have been caused by oysters at or about the date referred to in my circular letter. The fact as it stands calls for some comment. It is in accordance witli the experience of epidemiology that usually only a relatively small percentage of those who are exj)Osed to any given infection contract the disease in question. In this connection it has to be noted, that, as will presently appear, the EmsAVorth oysters, although they haA^e for very many years been exposed to the liability of pollution, are only actually thus polluted at uncertain, probably widely separated, intervals. It is not unlikely indeed that the majority of the oysters taken on any given date from the Emsworth grounds Avould prove incapable of conveying dehuite infection. I have had no personal opportunity of investigating' the cases referred to in the correspondence in Appendix No. 3, and I therefore refrain from any comments thereon. I may, however, add that it is not improbable, had my circular letter asked for information as to oyster-borne enteric fever generally, and hafl no specific dates been mentioned, the positiAm replies might have been more numerous. But my instructions did not cover so Avide a field. The negative replies AATich I receiA^ed were from the following places, and I take this opportunity of thanking the Medical Officers of Health of these localities for their kind assistance: — Tunbridge Wells, Newcastle-on- Tyne, Addlestone, Salisbury, Newport (Mon.), Torquay (reply received from Dr. M^inter, Chairman of Sanitary Committee), Southend, City of London, Bournemouth, Worthing, Ringwood, Bognor, Fareham, Devonport, Chichester, Lewes, Cheltenham, M^orcester, Gosport, and the Croydon Rural District. VENTNOR. Dr. Robertson, of Ventnor, has been good enough to furnish me vAuth the particulars of a case of enteric fever under his care, in regard of wdiicli the evidence points strongly to Emsworth oysters as having been the source of the infection. The case is of particular interest, owing to the fact that the patient had been under Dr. Robertson’s care for chronic bronchitis and emphysema since October 9th ; that all she ate and drank had been duly recorded since October 9th ; and that she had only been outside the house in Avhich she Avas lodging on. one or two occasions, and then only in an iiiAmlid chair. On October loth, 16th, 21st, 24th and 27th, and on NoAmraber 4th, Gth, 10th, 11th, and 14th, this patient partook of oysters which had been procured from Emsworth by the occupier of the house in Avhich she was lodging, no oy sters having been consumed either before or after these dates. This patient of Dr. Robertson fell ill with what proved to be a mild but typical attack of enteric fever on December 3rd. On page 47 Avill be found the temperature chart of this case. 1 am informed by Dr. Woodford, the medical officer of health of Ventnor, that there was no doubt whatever as to the oysters having come frA)m Emsworth, and I was able to ascertain myself at EmsAvorth that this AA^as the fact. The oysters were not procured from the same merchant who supplied the Winchester and Southampton banquets, but from the merchant who supplied the Portsmouth banquet. In the first instance this merchant asserted 14 emphatically that the oysters supplied to Yentnor, and which were probably the source of one case of enteric fever, came direct from Whitstable, and had not been stored in the Emsworth ponds ; but on being pressed upon this point he admitted that the oysters had been so stored. THE EMSWORTH OYSTER PONDS. Reference to the accompanying map will serve to show the position of the Emsworth oyster ponds, and the relation thereof to the Emsworth sewers. The Emsworth ponds are mainly the property of two oyster merchants, but certain of the ponds belong to the local fishermen, and are used by them solely for storing oysters. The oysters stored in these ponds are of different kinds ; they include French, American, Portuguese, and Deep Sea oysters. These are brought from abroad, or from the sea, and stored in these ponds until they are required for market. In a word, Emsworth is an important distributing centre for oysters of nearly all varieties. The ponds have been known to me since 1895. I pointed out at that date the dangerous position which they occupied in relation to the Emsworth sewer outfalls. The report which 1 then made was instrumental in bringing about a small improvement in the condition of affairs. Certain drains which in 1895 discharged directly among the ponds were intercepted and led to the main outfall. On the map now submitted the ponds from which the oysters for the Winchester and Southampton banquets were said to have been taken are coloured red, as also are those in which the Whitstable oysters which were supplied to the Portsmouth banquet and to the banquet to Lord Roberts are said to have been deposited pending their despatch to Portsmouth. Two ponds are marked red in each instance, because it is not quite clear which ponds actually represent those in which the oysters were deposited. The drainage of Emsworth.— 'i\\e house drainage of Emsworth is disposed of partly into privy-middens and partly into catchpits, which communicate in most instances by an overflow with the sewers in the neighbouring streets. The slop-water — including the sink-water, &c. — passes, generally speaking, wheilier there arc privy-middens or catchpits, directly into the sewers. These sewers have been constructed at different dates, and they consist partly of brick culverts, and partly of stoneware pipes. For the most part they are leaky, and their fall, in places, is deficient. They are neither properly flushed nor adequately ventilated. These sewers now discharge mainly by means of one outfall, which is situated in the channel of the estuary, near to the oyster ponds {see map), and which consists of an iron pipe, the end of which is covered with an iron flap. In addition to this main outfall there are others, some discharging into the river Ems under and near to the bridge crossing the river at the end of Queen Street, and another into the same river at the lower end of King Street {see map). As I stated as far back as 1895,* “ Af ivould hardly seem necessary., in view (f the relations between the sewer outlets and the storage pits depicted on the accompanying map, to diced upon the gross contaminations to which oysters here stored must he liable." The behaviour, pjast and piresent, of enteric fever in the town of Emsworth. — From a rej.ort drawn up by Dr. Lockhart Stephens, the medical officer of health of the Warblington tJrban District, it appears that enteric fever has * ‘‘ On Oyster Culture in Relation to Disease.” 15 been unduly prevalent in the town of Emsworth for many years. But I do not in this report propose to trace the behaviour of the disease further back than 1895, at which time Emsworth became administratively part of the Warblington Urban District, an area previously within the limits of the Havant Rural Sanitary District, The number of cases of enteric fever notified annually in Emsworth (population in 1901, 3,037) since 1895 has been as follows : — Years. Cases of Enteric Fever. 1895 20 1896 5 1897 7 1898 10 1899 10 1900 12 1901 17 1902 21 The cases occurring during 1902 were notified month by month as follows : — Month. ■ Cases of Enteric Fever. January ... 2 February ... — March 1 April — May ... ... ... — June 2 July 2 August 1 September — October 3 November 9 December... 1 In view of the suspicion which has attached to Emsworth oysters, it will be well to ascertain the position of the houses invaded in the place during October and November, and to enquire as to the destination of the drainage from such houses. Between October 22nd and December 8th, 1902, there were in all nine Emsworth houses (comprising 13 cases) invaded by enteric fever, and six of such houses were invaded before November 10th. The position of each of these nine houses will be found indicated by a red dot on the accompanying map. 16 The slop water of infected dwellings, which would be apt to contain the washings from bed linen, etc., as also probably some of the urine, passed in every instance but one into the , sewer, and in each case the catch-pit which received the excreta overflowed into the sewer. It may, in fact, be said that every house, save one, communicated in some measure with the sewer, and that specifically infected material from eight out of the nine houses had opportunit}^ ^of entering the outfall sewer which discharges near to the oyster ponds. llie source of the Emsicorth cases of Enteric Fever. — It was not until attention had been drawn to the Winchester and Southampton outbreaks that enquiry was made in Emsworth as to the part which Emsworth oysters may have had in disease causation in Emsworth itself, and at this comparatively late date there was the greatest difficulty in ascertaining the facts owing in no small degree to a disinclination on the part of the people of Emsworth to incri- minate the Emsworth oyster ponds. In many of the invaded houses there were it seems, sanitary defects ; but subsequent inquiries tended to show that Emsworth oysters were not improbably operative in causing fever in Emsworth to a greater extent than was originally believed. As I had no opportunity of personally investigating the Emsworth cases I do not propose to give a detailed account of them, but I have little doubt from the evidence which I have obtained, but of which I am not able to make public use, that oysters played a not altogether unimportant pait in the causation of enteric fever in Emsworth during October and November, 1902. When Dr. Lockhart Stephens was informed by the Medical Officers of Health of Southampton, Portsmouth and AVinchester, of the suspicions which they had formed with regard to the Emsworth oysters, he at once drew the attention of the Warblington District Council to the matter, and urged that a notice warning the public against the danger of eating shellfish from Emsworth should be published. This advice was, however, rejected by the District Council. Summary of facts brought out by this Inquiry. It may be useful at this stage to briefly summarise what are the alleged facts in connection with this altogether unique explosion of illness. 1. Two Mayoral banquets occur on the same day in separate towns several miles apart. 0 2. In connection with each banquet there occurs illness of anakigous nature, attacking, approximately speaking, the same percentage of guests and at corresponding intervals. 3. At both banquets not every guest partook of oysters, but all those guests who suffered enteric fever, and approximately all those who suffered other illness did partake of oysters. The exceptions to this rule appear insiirnificant when all the facts are marshalled. o 4. Oysters derived directly from the same source constituted the only article of food "which was common to the guests attacked. 5. Oysters from this source were at the same time and in other places proving themselves competent causes of enteric fever. Conclusion. \ The foreffoingf narrative of facts would seem to establish the strongest possible presumption that oysters which had been deposited for a time at Emsworth have caused the outbreaks of enteric fever and other illness which followed the Mayoral banquets on November 10th at AVinchester and Southampton. A 17 It would seem, too, that the series of cases at Portsmouth referred to by Dr. Fraser in his report also contracted their enteric fever through oysters procured from Ems worth ; and, from further evidence supplied in this report it would appear that Emsworth oysters may also have been operative in the pro- duction of fever in places other than Winchester, Southampton and Portsmouth. It will, necessarily, be asked : why, if the Emsworth oysters were respon- sible for the illness following the Winchester and Southampton banquets, no conspicuous illness followed the two banquets at Portsmouth, seeing that the oysters supplied to those other banquets had also been deposited in the Emsworth ponds. It may further be asked why, in view of the long time which the Emsworth oyster ponds have been exposed to sewage pollution, no such occurrences as those here under consideration have been previously brought to light. The answer is, I think, this. It is only occasionally that enteric fever has been prevalent in Emsworth. On such occasions the specific bacilli in the excreta may not always have escaped the disinfecting process to which the stools are usually subjected, or, if they did thus escape, they failed to maiiuain their potency for harm in face of the antagonistic influence of other bacteria in the sewer. Or, again, if they survived they may have rapidly perished on reaching the outfall. Laboratory experiments tend to show that the Eberth- Oaftlky bacillus has no great expectation of life in sewage, and. furthermore, that it does not, again under laboratory conditions, survive indefinitely in sea water. Nevertheless, laboratory experiments do tend to show that the bacilli in question may survive long enough to reach the Emsworth outfall, as well as, under the topographical circumstances of the Emsworth ponds, long enough to reach these ponds. Laboratory experiments also show that the enteric fever bacillus having once reached the oysters may survive therein sufficiently long to enable the bacillus to pass to the consumer with the oysters. It is obviously an assumption without sufficient warrant to infer that what takes place in a tank of sea water procured from a certain source will of necessity also take place in an estuar}' consisting partly of fresh and partly of salt water, which estuary may contain other lower forms of life, animal and vegetable, capable of influencing favourably or adversely the vitality of the enteric fever bacillus. Few competent bacteriologists would, I think, make any such claim, and there is obviously need for further investigation into the fauna and flora of sea and brackish water before we can forecast what, under any given circumstances, will be the behaviour therein of the enteric fever bacillus. However this may be, looking at the outbreaks here, under consideration from the epidemiological standpoint, it seems to me to be a matter of practical certainty that some of the enteric fever dejecta which found its way into the Emsworth sewer from one or other of the cases of enteric fever which occurred antecedent to November 1 0th, did as a matter of fact carry living enteric fever bacteria into the Emsworth channel, which bacteria, on the rising tides, found their way into the ponds from which the oysters supplied to the banquets were taken. What were the circumstances which enabled this infectious material to resist adverse influences until it was carried into the pond or ponds from which the oysters for the Winchester and Southampton banquets were taken, aud what the conditions which seemingly safeguarded these ponds during the shorr time during which the oysters for the Portsmouth bampuet were deposited in them, I am unable to say. Bacterioloiiical examination of the ivater and oysters from the Emsworth 'ponds. — When I visited Emsworth in connection with the enquir}' now in question I was pressed by the oyster merchants (and I see by Dr. Fraser’s report that similar pressure was brought to bear upon him) to take samples of the water and oysters in the ponds and to submit them to the bacteriologist for examination. My rej)ly was that 1 had been familiar with these ponds since 1895 ; that I had at that date expressed my opinion as to the dangers to which oysters deposited therein were liable ; and that no negative testimony, either chemical ot* bacteriological, would undo the fact that the oysters were laid down within a few yards of the main sewer. Moreover, a positive result 13593 0 18 in either case Avould be superfluous. This attitude I adopted because I considered that if this outbreak of enteric fever had been caused by the Emsworth oysters, the science of epidemiology should be competent to demon- strate the fact. How far I have — with the hearty co-operation and assistance of Dr. Fraser, Dr. Langdon, Dr. Lauder, Dr. Lockhart Stephens, and others — been able to afEord such demonstration may be judged of from this report. Moreover, I had recently seen a bacteriological analysis of alleged Emsworth oysters in which it was stated that such oysters were free from sewage con- tamination, and the experience which I gained in my enquiry in 1895 had gone far to show me that, at any rate at that date, negative results might be yielded by particular samples taken from situations obviously liable to contamination by sewage. It is, moreover, not unusual for a sample of water to be taken at the mouth of an estuary, on the top of the flood, and, if this sample is regarded as satis- factory by the bacteriologist, the certificate relating thereto is utilised to cover all parts of the fishery. Clearly, regard should be had to the state of tide, as also to other parts of the fishery from v^hich no samples have been taken. In a word, negative bacteriological evidence may be highly misleading, and, as regards positive evidence, it is desirable that there should be some agreement among bacteriologists as to the precise significance, both as regards presence and number, of B. coli communis and B. enteritidis sporogenes before a bacterial standard can be applied either with safety to the consumer or justice to the oyster industry. It may, however, be added that, as a matter of fact, specimens of water and oysters from -the Emsworth ponds were examined by Dr. Klein, which, in December, 1902, were found to contain bacteria of sewage origin in abundance, albeit the enteric fever bacillus was not discovered by him in these oysters. In concluding this report I wish to place on record my indebtedness to a number of persons who have afforded me assistance in connection with this enquiry. In connection with Winchester, my thanks are due to the Mayor (J. A. Fort, Esq.), the Town Clerk, and Dr. Langdon (the Medical f'fficer of Health), for their cordial co-operation during the enquiry, as also to all those medical s^entlemen who were yood enouo-h to afford me information as to cases under their care. As regards Southampton, I have received very great assistance from Dr. Lauder, the Medical Officer of Health, who took especial ]>ains to furnish me v.dth the numerous details necessary for this report, and I have also to thank the Town Clerk for his co-operation, as well as all those medical practitioners who gave me information as to their cases. With respect to Portsmouth and Emsworth I have to acknowledge with gratitude the assistance of Dr. Mearns Fraser and Dr. Lockhart !Stei)hens, as also, at the former place, that of Alderman Emanuel, J.P. I also received assistance from the oyster merchants at Emsworth, and from others whose names space will not allow me to mention; but who will, I trust, accept this acknoAvledgment of the help they rendered me. H. TIMBRELL BULSTRODE. Note on the Storage of Oysters in Shoes. I think that it may not be altogether out of place if I here draw attention to the imjiortance, from the point of view of the public health, of greater care being exercised in the storage of oysters. Although it is unlikely that oysters stored in shops should become specifically polluted by the excreta of enteric fever it is in my view probable — -albeit I am satisfied that no such influence has been operative in the series of cases under consideration in this report — that at least some of the acute diarrhoea and vomiting, which is by no means rarely observed after the ingestion of oysters, may be caused by oysters kept so long in the shops that when sold they are practically moribund. I do not propose to mention the towns where instances of oysters exposed for sale in a moribund state have come beneath my notice, but I may add that in the course of my experience I have seen multiple examples of this. I can recall an instance in which having examined certain oyster layings, and being satisfied that they were free from sewage |X)llution, I entered a shop in a neighbouring town to procure some oysters for consumption. Before purchasing the oysters 1 asked to see them, and I found so many in a moribnnd condition that I deemed it unsafe to partake of any. I have recently had a very similar experience, and I am far from satisfied with the manner in which oysters are stored. It is not nncommon to find several dead or dying oysters among those exposed for sale, and it is not improbable that the toxic symptoms oljserved after the consumption of oysters may, in some cases, be due to this cause. The frequency of these attacks of gastro-enteritis after the consumption of o}"sters and other molluscs is not, I think, adequately appreciated, a fact which is probably due to the circumstance that such attacks are rarely fatal. Several attacks of this nature have been recorded in this country, and, as regards France, Dr. Mosny has brought together a mass of information in a valnable report which he made on the subject to the French Government. The shells of all oysters should be thoroughly cleansed by scrubbing before the oysters are placed in a common receptacle, and such receptacle should be constructed of white impervious material, and not used for other purposes. Weak oysters should be at once removed. It is, however, desirable that oysters should be procured daily from the “ beds,” “ layings,” or “ ponds,” and that the shells should be thoroughly cleansed before being despatched therefrom. The shells of a healthy oyster should be either tightly closed, or, if apart, they should, when the oyster is held flat between the fingers and thumb, be felt to be gripped together by means of the powerful adductor muscle with which the oyster is provided. If the shells gape, and do not at once, and vigorously, close on handling, the oyster should be rejected. H. T. B. C 2 1359S 20 APPENDIX No. 1. Contents. (a.) Copy of communication sent to each guest. (&.) A table showing the articles consumed at the Winchester banquet, and the returns of the illness from which certain guests suffered. (c.) A list of the articles used in the preparation of the banquet, and the sources from which they were procured. (d.) Notes on the enteric fever cases. (a.) Dear Sir, Guildhall, Winchester, December 20th, 1902. The Sanitary Committee of the Corporation, acting on the advice of their Medical Officer of Health, are anxious to ascertain certain additional facts with regard to the illness which followed the recent public banquet of November 10th, and they will be much obliged if you will be good enough to supply them with some special information. There is furnished herewith a form containing a list of the articles of food consumed at the banquet. You are requested — (1.) To place a ( + ) opposite the articles of which you partook, a query (?) against those concerning which you are not in a position to make a positive statement ; no mark against those articles which you did not consume. (2.) To answer the questions printed on the form. (3.) To return the form filled up, if possible, by return of post, to T. C. Langdon, F.R.C.S., Medical Officer of Health, Guildhall, Winchester. I am, dear Sir, Yours faithfully, J. A. FORT, Maj'or. Did you suffer any illness or serious inconvenience after the banquet ? If so, do you attribute such illness to the banquet ? If so, how long after the banquet did such illness commence ? If so, what was the nature of such illness ? Please return to T. C. Langdon, F.R.C.S., Medical Officer of Health, Guildhall, Winchester. 21 Oysters Clear Soup ... Thick Soup Smelts Turbot and Lobster Sauce Sweetbread and Spinach ... Kidneys and Mushrooms... Boiled Mutton Boast Mutton Boast Beef ... Venison Bed Currant Jelly ^Capons Ham ... Tongue Turkey Pheasant Partridge Sir Watkin Wynn Pudding Charlotte Busse Liqueur Jellies Caramel Cream Maraschino Cream... Meringues ... Ice Cheese Salad Aerated Water, which ? ... Column for Marks. Bemarks. The Winchester Mayorar Banquet. cc 5 CJ 5 ^ S,* •nk. <4; $' Jj 2S o. . Violent diarrhwa folloivhu/ day. 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T. a. ... W. L C. R M. W H. J. A. K fr. s. M. T. F. K N. C. H. N a; J. c. w E. E.S BI. J. R Dr. B S. C S. <’. GO * Iff * «■ * ►I— •»_ * uaqran^ ’T' 5 Iff Iff Iff iff iff uj Iff Iff 25 1S693 D Articles consumed. — = Articles not consumed. * = Illness. t = Enteric fever. 26 iS 1 Gs| pH CO u ci a CO uniting 48 hours L02. Never gui1 , and. on Novembe: lave enteric feve § 5 «9 2® «o s t) «9 ' 13th ; vom ited m, ft 1 I •S r«4 2 § hS «9 ! ; Diarrhoea and vc banquet. T. ] covered health, was found to 1 'di •«>a 59 (M r«> ft si S <3 .1 “ Queer Kovember November Hth. Nausea and violent and \3th. 5»i 'I . 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Commercial Road, Landport. Oysters on November 11th ; taken ill on December 1st. Notified on December 8th. 4. — Mr. P. B., Commercial Road, Landport. Oysters on November 12th; taken ill on November 25th. Notified on December 8th. 5. — Mr. S. B., Commercial Road, Landport. Oysters on November 12th; taken ill on November 28th. Notified on December 8th. 6. — Miss C. B.. Commercial Road, Landport. Oysters on November 12th ; taken ill December 5th. Notified on December 8th. {The above four were members of the same family.') 7. — Mr. W; S., North End Grove, North End. Oysters on November 11th; taken ill on November 21st. Notified on December 7th. 8. — Mr. C. W.. Union Street, Portsea. Oysters on November 8th ; taken ill on November 29th. Notified on December 9th. 9. — Mrs. F. G.. Shaftesbury Road, Southsea. Oysters on November 13th ; taken ill on November 22nd. Notified on December 9th. 10. — Mrs. P. W., Gains Road, Southsea. Oysters on November 22nd and 24th ; taken ill on December 3rd. Notified on December 10th. 11. — Miss F. A.. Lake Road, Landport. Oysters on November 12th ; taken ill on November 20th. Notified on December 10th. 12. — Miss E. A.. Lake Road, Landport. Oysters on November 12th ; taken ill on December 5th. Notified on December 10th. {The above two are members of the same' family; and as the second ease E. A. was tahen ill fifteen days after the first, it is possible the second case was caused by personal infection, and therefore only ind'irectly due to oysters.) 13. — Mrs. K., Shaftesbury Road. Southsea. Oysters several times from November 1st to the 10th ; taken ill on November 27th. Notified on December 11th. 14. — Mr. J. H., Nelson Road, Southsea. Oysters on November 10th and 18th ; taken ill November 29th. Notified on December 12th. 15. — Miss. L. B., Commfercial Road, Landport. Oysters on November 21st and 29th ; taken ill December 2nd. Notified on December 12th. 16. — Mr. W. L., Osborne Road. Southsea. Oysters taken on numerous occasions during November; taken ill November 27th. Notified on December 14th. 17. — Mr. E. B. A., Nightingale Road, Southsea. Oysters on November 26th, 30th, and December 7th; taken ill December 9th. Notified on December 4th. 18. — Mrs. E. H., Somers Road, Southsea. Oysters on November 21st ; taken ill December 7th. Notified on December 16th. 19. — A. H., Somers Road, Southsea. Oysters on November 21st ; taken ill December 12th. Notified on December 16th. 20. — Mrs. C. T., St. Ronan’s Avenue, Southsea. Oysters on November 14th ; taken ill on Decembf r 2nd. Notified on December 18th. 21. — K. B., Derby Road, North End. Oysters on November 16th; taken ill on December 8th. Notified on December 20th. 22. — Miss H. W., Osborne Road, Southsea. Oysters November 14th ; taken ill December 6th. Notified on December 18th. 23. — Mr. S. W., Osborne Road, Southsea. Oysters three times a week during November; taken ill on November 30th. Notified on December 16th. 24. — Mr. 0. P., Hampshire Terrace, Southsea. Oysters on December 6th and 13th ; taken ill on December 20th. Notified on December 21st. 25. — Mrs. F. A., King Street, Portsea. Oysters nearly every day from November 17th to 27th ; taken ill December 7th. Notified on December 19th. \ F 2 13593 44 Confidential. Local Government Board, Whitehall, S.W., December, 1902. Dear Sir, I AM investigating, under the instructions of the Local Government Board, an outbreak of enteric fever in Hampshire Avhich is alleged to have been caused by the consumption of oysters eaten raw. I have reason to believe that oysters from the suspected sources were introduced into your district during the second week in November, and I should be extremely obliged if you could kindly inform me if any cases of enteric fever or gastro-enteritis have occurred in your district at a date which would suggest infection at or about November 10th. If so, might 1 ask whether oysters had been taken at or about the date in question, and, if so, what is the name of the fishmonger from whom the oysters were procured. To Dr. Medical Officer of Health. I am , dear Sir, Yours faithfully, H. TIMBRELL BULSTRODE. GUILDFORD URBAN SANITARY AUTHORITY. Medical Officer’s Department. Guildford, December 28th, 1902. Dear Sir, In reply to your letter of the 27th inst., I am glad to say that the only two recent cases of enteric in this district were undoubtedly due to direct infection, as these patients contracted the disease whilst nursing an enteric case at Woking. In September I had a case, and the only possible cause that I could discover was that the boy had eaten shell-fish at Portsmouth a fortnight previously. Dr. Bulstrode. Believe me, dear Sir, * Yours faithfully, ARTHUR M. MITCHELL. METROPOLITAN BOROUGH OF WANDSWORTH. Dear Dr. Bulstrode, Public Health Department, 1, Huguenot Place, East Hill, Wandsworth, S.W., 31st December, 1902. I enclose list of enteric fever cases which have occurred since the 1st December in this district, attributable to shellfish. The cases infected by cockles were perfectly clear, and both Dr. Watson, of Leigh-on-Sea, and Dr. Thresh, Medical Officer of Health for the County of Essex, have been informed. The case occurring at No. — , M Road Clapham, notified on the 8th December, was, as you will see from the letters enclosed, almost certainly due to Emsworth oysters, but in the case at No. — , Old Town, I could not ascertain from what part the oysters had come. Any further cases I shall report to you immediately on notification. I may say that Dr. Klein has been investigating the cockles, and I have no doubt he will send you a copy of his report shortly. Dr. Bulstrode, Local Government Board. Yours faithfully, CALDWELL SMITH, Medical Officer of Health. 45 Enteric Fever prom Shellfish. Date of Notifica- tion. Name of Patient. Age. Address. j Date of First Symptoms. Suspected Source of Infection. 1902. / Dec. 1 ... T. D. 20 Chip Street, Clap- ham. Nov. 15 ... Patient had some cooked cookies on the 1st November. The cockles were purchased from a man named G., who bought them from a man P. at Billings- gate market. P. came from Leigh-on-Sea, near Southend, and brought the cockles from there. „ 1... A. D 16 Chip Street, Clap- ham. „ 22... Patient had some cockles on the 8th November, obtained from same source as her brother above. „ 1... N. D 18 Chip Street, Clap- ham. „ 15 .. Patient had some cooked cockles on 1st November. Particulars as above. „ 4... J. 0 31 Baker’s Cottages, Prescott Place, Clapham. „ 19 ... Patient had some cooked cockles purchased off the man G. men- tioned above on 8th November. „ 6... E. 0. 32 Hazelbourne Road, Streatham. „ 29 ... Patient had some oysters two weeks previously, also on 27th November. „ 12... ,W. K 50 Old Town, Clapham About two weeks ago. Patient had some raw oysters pur- chased by a Mr. S., probably purchased from Mr. R., Billings- gate Market. „ 8... 0. Y 28 Macaulay Road, Clapham. Nov. 29 ... Patient had some oysters bought at a shop near London Bridge Station. QSee copy of letters.) „ 22... H. C. 2 Lyddon Road, Wandsworth. Dec. 9 ... Patient had some boiled mussels eight weeks previous. „ 26... D. U 14 Gartmoor Gardens, Wandsworth. „ 20 ... Patient had some raw oysters on 19th December. 1903. Jan. 7 ... A. C 40 Bedford Hill, Balham. „ 26 .. Patient had some raw oysters on 7th or 8th December. „ 9... G. R 21 Fircroft, King’s Road, Clapham Park. „ 30... Patient had some raw oysters on 7th or 8th December, purchased from a Mr. M., who obtained them from Mr. D., of Lower Thames Street. „ 12... M. A. C 53 Lebanon Gardens, Wandsworth. „ 27... Patient had some raw oysters about six weeks previous. METROPOLITAN BOROUGH OF BERMONDSEY. Public Health Department. Dear Sir, Town Hall, Lower Road, S.E., 20th December, 1902. Assuming that the incubation period of your case was 14 days, and the first symptoms came on on November 29th, the disease might possibly be acquired about the 15th or before. I find that on November 10th, 14th, and December 3rd this man got consignments of oysters from Emsworth as follows : — November 10th 14th December 3rd 1,300. 1,000. 1,000. It is therefore quite possible that the source of infection may be Emsworth oysters. Dr. P. Caldwell Smith, Medioel Officer of Health, Wandsworth. Yours faithfully, R. K. BROWN, Medical Officer of Health. 1 46 Town Hall, Eastbource, Sanitary Offices, December 30th, 1902. SIR, In reply to your letter of the 27th December, I beg to inform you that on November 25th a case of enteric fever was notified to me in Eastbourne about which there was some doubt as to the possibility of oyster infection. The case was a very bad one and quickly fatal, and as he was a soldier of 23 I have been unable to get definite information about oysters as his friends did not know what he might have been doing. On December 22nd a case of enteric fever was notified to me of a man who had been already ill about a fortnight and ivho had partaken largely of oysters about the date you mention. He obtained these oysters, as I am inf ormed, from a fishmonger named X. There have been but three cases (although six notifications) of enteric fever in Eastbourne this year. I am. Sir, Yours faithfully, W. G. WILLOUGHBY, H. T. Bulstrode, Esq., Local Government Board, Whitehall, London, S.W. Medical Officer of Health. N.B. — I have not been able to trace the oysters referred to above to Emsworth. H. T. B. BRIGHTON. Information furnished by Dr. Arthur Newsholme, Medical Officer OF Health. January 19, 1903, List of cases of Typhoid Fever occurring in Brighton during 1902, m which oysters from Emsworth had been partaken of within three weeks of the onset of the atta(^. (1.) Mrs. F., aged 27, wife of a cabinet maker of No. 29, G. Street, failed with typhoid fever about the lOtli July, and kept her bed from the 19th. On or about June 26th she ate 10 oysters, the last of which she states was “ bad.” On July 4th, she and her mother ate four oysters each. The mother has remained well. The oysters were obtained from No. 82, C. Street. The proprietor of this shop obtains a portion of his oysters from South- wick and a portion from Emsworth. No other cases of typhoid fever occurred at this house, and the total number of such cases notified in Brighton during the months of June and July was only 10. No other cases occurred in connection with the same milk supply. The house was in a completely sanitary condition. (2.) Mrs. S., aged 55, of No. 14, B. Place, failed with typhoid fever about October 12th. On October 5th she went to Emsworth, returning to Brighton on the 12th. While at- Emsworth she had oysters several times. She stayed in Emsworth during the whole six days she was away from Brighton, On October 12th before returning to Brighton sho had oysters for lunch. During the rest of the day she felt well, but next morning on getting out of bed she vomited and had severe diarrhoea. The diarrhoea lasted for several days. She was then better for a week, but after that was under a doctor’s care for about a week before her admission to the Borough Sanatorium on November 16th. The sanitary condition of the house in which she lived in Brighton is good. There was no special prevalence of typhoid fever in Brighton at that time ; the total number of cases notified during the month of October being only eight. There were no other cases in connection with the same milk supply. (3.) Alice B., aged il8, of No. 12, B. Street, a barmaid failed with typhoid fever on November 24th. This patient and her sweetheart had oysters about three times weekly for three weeks during the weeks beginning at the end of October. She usually ate seven to 14 oysters on each occasion. Her sweetheart has remained well. The oysters were bought at No. 82, 0. Street, the same shop as above, and are obtained from Southwick and Emsworth. The proprietor of the inn where this patient was barmaid, failed with typhoid fever on October 4th, the attack being traceable to oysters derived from Grimsby. The ]>atient was nursed by a trained nurse and every precaution taken, but as Alice B. did not leave the inn for 10 days after the onset of the proprietor’s attack of typhoid rever it is conceivable that her attack was caused by personal infection, though more likely that it. was due to the oysters which she partook of at No. 82, C. Street. 47 (4.) George G„ aged 40, of No. 77, S. Street, a detective at race meetings, failed with typhoid fever on December 1st. He had been living at the above address or one before the onset of his illness. Early in the third week of November he bought and ate six oysters at No. 28, N. Eoad. At No. 77, S. Street, there are living six other persons, who have remained well. The oysters at No. 28, N. Road, are obtained from Emsworth and the Whitstable Company. (S.) John B., age 34, of No. 71, B. Road, a grocer, failed with typhoid fever on December 19tb. On or about the first week in December he ate a few oysters at the above shop in N. Road. There are living in the same house with the patient, his wife, two children, and two servants, all of whom have remained well. The patient does not a e milk except in puddings. The sanitary condition of the house is good, and no o er source of infection can be discovered. The total number of notifications of typhoid fever in each month of 1902 has been as follows : — January February March April ... May ... June ... July ... August September October November December 7 3 2 3 3 3 7 5 5 8 8 11 Total 65 BOROUGH OF HOVE. Town Hall, Hove, Sussex, t January 30th, 1903. Dear Dr. Bulstrodb, The case of enteric fever associated with oysters which I mentioned’ was as follows : — C. R. S. ate oysters on October 12th, obtained direct from Emsworth. The history of the case is as follows : October J3th, violent diarrhoea till 16th when he took castor oil which stopped diarrhoea. October 20th, began to have headache and felt shivering, after which illness followed usual course of mild enteric fever I am. Yours faithfully, A. GRIFFITH. TEMPERATURE CHART OF Dr. ROBERTSON’S CaSE. 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