1089SHELL-FISH AND DISEASE.

Shell-fish and Disease.

THE LANCET.

LONDON: SATURDAY, APRIL 22, 1911.

A VERY comprehensive and highly instructive report uponthe relation of enteric fever and gastro-enteritis to the con-

sumption of certain shell-fish has recently been made to theLocal Government Board by Dr. H. T. BULSTRODE. As longago as 1896 Dr. BULSTRODE wrote his well-known reportupon oyster culture in relation to disease, and since that timematerial improvement has been effected in the conditions

under which these molluscs are cultivated and prepared formarket. But Dr. BULSTRODE is now forced to observe that

"notwithstanding such improvement much still remains to

be done before the public can consume oysters boughtpromiscuously with a reasonable degree of safety." The

present report relates mainly to mussels and cockles-

that is to say, to the molluscs of the poorer classes-and

many persons unacquainted with the scale upon which these I

shell-fish are consumed in some of our large towns will beastonished at the enormous amount collected and despatchedto market from all parts of the English and Welsh littoral,as well as from Ireland, Scotland, Holland, and elsewhere.The mussel and cockle industry differs essentially from the

oyster industry in that the less costly shell-fish are scatteredin a promiscuous manner over the littoral, whereas the

oysters are more cultivated and confined to certain definite

areas. But there are furnished in the report before us twoinstructive maps showing the chief localities from which

mussels and cockles are gathered, and the localities from

which certain of the large towns are supplied. From these

maps it is clear, as the author insists, that legislationo! regulations to be effectual should comprise, not onlyEngland and Wales, but also Scotland and Ireland ; and

it must, moreover, especially as regards oysters and mussels,take note of the conditions obtaining in Holland, America,and France.

It is by no means an easy matter to bring about the

safety of shell-fish beds already exposed to pollution, andwe are glad to see that this point is made abundantly clearin the report. Under existing conditions it is possible for

large sums to be expended upon sewage purification works and yet for the effluent to contain enormous numbers of ]

sewage bacteria. Even were it practicable at a reason- (

able cost to efficiently sterilise this sewage in ordinary times, 1

the difficulty of periodic outflows of untreated, although highly diluted, sewage through the storm overflows remains.Dr. BULTRODE takes his readers upon an imaginaryjourney around the English and Welsh littoral, and shows t

them, by means of maps and descriptions in the text, the Eactual conditions which obtain in every place of importance, a

with respect to position of the shell-fish and to the t

methods adopted for storing and cleansing them prior to c

consumption. In both particulars the revelations made are

decidedly disquieting, and there is no shadow of doubt leftas to the necessity for legislation and active administrativeaction. We read, for example, with reference to importantmussel and cockle supplies, that although the shell-fish maybe collected from localities relatively remote from con-

tamination by sewage, the shell-fish may be brought backand cleansed on shore much too near to the mouths of

sewers. With respect to the actual dangers involved byinfected shell-fish, Dr. BULSTRODE shows that, except in

dealing with definite outbursts of enteric fever such as

occurred after the banquets at Southampton and Ports-

mouth, the testimony is usually of a very circumstantial

nature, which only becomes convincing in its cumulative

aspects. He furnishes, however, a body of well-arrangedevidence which leaves no doubt in the mind of the reader

as to the correctness of the inference that both enteric

fever and gastro-enteritis are not infrequently caused bythe consumption of mussels and cockles eaten raw or im-

perfectly cooked. Two charts relative to enteric fever in

England and Wales from 1870 onwards show that from 1875to 1885 there was a steady fall in the death-rate from this

disease, that between 1885 and 1899 the rate was apparentlystationary, while from 1900 onwards there has been a marked

decline; and the point which has to be determined is as to the

degree of influence which abstention from polluted shell-fishhas played in the decline during the present century. Dr.

BULSTRODE takes the enteric fever death-rates in two groupsof towns : one group in which much attention has been paidto shell-fish and the other in which the question has assumedbut little prominence. These several death-rates are after-

wards compared in a single table, and it is shown that in

many instances in both groups of towns during some periodduring the years 1898-1902 a decided fall in the enteric feverdeath-rate occurred which has for the most part been main-

tained, and this fact is true whichever group of towns is

considered. Dr. BULSTRODE regards these declines as

provisionally suggesting that in one town shell-fish, in

another the abolition of the conservancy method of

excrement disposal, and in another the removal of some

other cause as yet undetermined, may have been the

dominant factor in promoting the said decline, and he

regards it as not improbable that in some places, as was

presumably the case at Belfast, the enteric fever is beingunwittingly maintained by the non-recognition of shell-fishinfluences. This inference leads him to appeal for more

detailed investigation into the history of individual cases ofenteric fever, a research which can only in some instancesbe properly carried out by affording to the medical officer ofhealth more skilled assistance than he has as yet at his

iisposal. The report also discusses in suggestive fashion the

possible influences of shell-fish in maintaining the seasonal?revalence of enteric fever, a subject which is beset with

very great difficulties.This very interesting report is summed up by concluding

hat so long as existing conditions, both as regards homend foreign shell-fish, obtain, those persons who desire to

!.void contraction of enteric fever or gastro-enteritis from,his source should either abstain entirely from shell-fish

r consume them only after they have been actually at the

1090

boiling point for at leastfive minutes. It is simply astonish- v

ing, after all the public attention which has been drawn to i

,this subject of shell-fish infection, to read in the report f

before us that at the present time there is practically no c

.,adequate control in a sanitary sense exercised over places c

from which shell-fish are collected or over places wherein c

’they are laid down, washed, or stored; and it is t

earnestly to be hoped that Parliament, after reading this i

’report and examining the maps which it contains, will at I

host insist on one or other of the remedies discussed by Dr. EBULSTRODE being applied without further delay. s

Some Plans for Medical Reform,1IN the rapid economic changes of an age of flux the

medical profession is finding itself face to face with problems,and solutions of these problems, which shake its traditional

organisation to the foundations. Impending legislation,sooner or later and in some form or another, will deal with

- some of these problems and will adopt some of the solutions

put forward, since both political parties are more or less

committed in theory to a reform of the Poor-law, and there-fore to immense interference with’ medical practice as it is.

Much earnest thinking is now being employed upon the

adjustment of medical service, upon how this can be

effected with the least disruption of ancient and cherishedideals, and with the least disturbance of our fundamental

professional canons, and in these circumstances every

intelligent effort to point out a direction in which order

may be restored deserves the close attention of our readers.

The authors of the small books which prompt these words

.approach the whole matter from different points of view ;Mr. COURTNEY BUCHANAN being conservatively inclined,while Professor MOORE’S proposals are radical and destruc-tive. To consider first the smaller work in relation to hospitalpractice, Mr. BUCHANAN, whose experience in hospital,administration entitles him to a respectful hearing, notes thatthe main point of difference between the Majority and

Minority Reports affects the machinery to be introduced,.and he makes an attempt to bring into line the functions ofthe voluntary hospitals as they are now exercised with therecommendations contained in both reports. He insists on

the all-importance of I I the human factor," both in publicassistance and in hospital work, and all his views

are based on a continuance of the hitherto existingideal of the medical profession as ministering to the

individual well-being of the poor, either by the relief

of occasional distress or by the amelioration of their

character and habits, and so of their condition. He

confines his inauiry, therefore, to the proposed basis of

cooperation between the various State and voluntary agenciesfor medical assistance, and endeavours to define what shouldbe their respective departments. He foresees that the effect

of legislation will be that the response to charitable appeals

1 The Function of the Voluntary Hospitals in Relation to the Pro-posed Public Assistance Authority. By J. Courtney Buchanan, ofLincoln’s Inn, Barrister-at-Law, &c., Secretary of the MetropolitanHospital, London. Second edition, revised and enlarged. London:The Hospital Gazette. 1911. Pp. 74. Price 1s. net.The Dawn of the Health Age. By Benjamin Moore, M.A., D.Sc.,

M.R.C.S. Eng., L.R.C.P.Lond. London : J. and A. Churchill. Liver-pool: The Liverpool Booksellers’ Co., Limited. 1911. Pp. vii.-204.Price 3s. 6d. net.

will grow less and less, and that sooner or later the hospitals,.f they are to continue to do the same work, must have someorm of State aid or municipal subvention. This prophecycoincides with the views expressed in our correspondencecolumn by "M.B.," writing upon the I I trust " danger in

charity, for "M.B." points out that the orderly opera-

tions of the big hospital funds have adversely affected

individual subscriptions to particular charities. Mr.

BUCHANAN believes that this cooperation between the

State and the voluntary agencies can occur without

submitting the voluntary hospitals to State control, which

we agree with him in thinking would present many causesof regret. After reviewing the work of the hospitals in

regard to in-patients and out-patients, to their classificationand general control, to their educational value, as well asto their cooperation with the general practitioner, the

public health authorities, the Poor-law authorities, and theambulance service, he suggests a scheme, the main featuresof which are that the voluntary hospitals should be con.trolled by a central council and be reserved for treatment

by consultants. All patients should contribute, he holds,according to their means, and a provident dispensarysystem (which should be a sort of clearing-house for

patients or court of first instance) should be introduced

and maintained by a public assistance authority ; the hos-

pital out-patient departments would thus be used only forconsultation purposes between the staff and general practi-tioners on behalf of their poorer patients. By this meansall patients reaching the hospitals would have been pre-

viously examined and found suitable cases for hospitalcare by medical men. A vast amount of clinical material

would thus become available for teaching, while the volun-

tary hospitals would retain their individuality. The central

council to control the voluntary hospitals should, he suggests,be elected from the working members of the respectivehospital committees and the councils of the great hospitalfunds, and remain entirely independent of any public assist-ance and of the Poor-law authority. The council would

constitute a separate service, the system of lay secretaries

being retained to check extravagance and to preserve orderin administration. The work of the hospital, leavingemergencies out of calculation, would be consultative, andthe classifying of patients would be done in the providentdispensaries. The hospitals would be kept up to the mark

by the council, which should have on it representatives of allprofessions and be divided up into subcommittees to look

after property and finance and catering. Such is a brief

outline of Mr. BUCHANAN’S attempt to grapple with the

great hospital difficulty, by showing how these voluntarycharities might retain their individuality and yet comeinto closer relation with the public and the generalpractitioner.

If Mr. BUCHANAN attempts to accommodate existingorganisations to the tide of advancing communistic

ideals, Professor MOORE will have none of these com-

promising methods. He advocates the extermination of

our present systems of medical aid altogether. The

problems of disease, he thinks, require to be tackled, notso much by medical men as by statesmen or economists. He

demands a disciplined army to fight disease, stating that the