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34
Annual Report of the London County Council, 1911.
tion to a case recognised only after death. In Deptford the mortality rate is said to be the lowest
on record. Dr. Davies makes mention of 4 cases occurring in Woolwich amongst persons supplied
with milk from a particular dairy where a girl was employed who had had enteric fever a year-anda-half
previously.
In each of the annual reports of Dr. Thomas, the medical officer of health of Finsbury, for 1910
and 1911, special reference is made to localised prevalences of typhoid fever and to possible sources of
infection. For instance, the suggestion is made that hawkers suffering from incipient typhoid fever,
while selling watercress or fruit, may be a means of spreading the disease. A further possibility considered
is the existence of undiscovered "carriers"; and in the case of an outbreak including upwards
of 50 cases in September, 1911, infection by means of missed and early cases of patients, some of
whom "fed and ate in the neighbouring ice cream shops and fried fish and other restaurants and
possibly infected the feeding utensils."
In connection with the outbreak last referred to, question arose as to whether cases occurring
in other parts of London were due to one and the same cause as the Finsbury cases, and all the circumstances
were, therefore, studied in detail by me, and I received every assistance from Dr. Thomas
and his staff. My report was submitted by Sir Shirley Murphy to the County Council, and is set out
in extenso in Chapter XXXIII. As Sir Shirley pointed out, "prima facie there were some grounds for
suspecting that the outbreak might possibly have been due to ice cream" but an analysis of all the
evidence "failed to show any other explanation than the consumption of fried fish as the cause of
the prevalence." Dr. Thomas in his report for 1911 criticises the fried fish and ice cream hypotheses
and states that all the cases cannot be satisfactorily explained on the basis of infection by one or the
other of these two food substances. Dealing with the theory of fried fish infection, he raises doubt
as to the reliability of the statements made by the sufferers under examination; he also refers to the
temperature difficulty and points out that the evidence in favour of the fish theory is based upon
statistical grounds, and that it is thus a "statistical probability " that is raised.
At the commencement of the Finsbury outbreak there was some ground for suspecting icecream,
inasmuch as more than one-third of the sufferers had obtained this article of food from one
particular source ; but 35 of the 56 sufferers had not partaken of ice cream. On the other hand, no
fewer than 52 of the 56 persons in whom the diagnosis of typhoid fever was confirmed had partaken
of the suspected fish, and having regard to the extent of the area involved in Finsbury and the degree
of prevalence of typhoid fever in London at the time, 3 or 4 individuals may be regarded as representing
sporadically occurring cases of the disease unconnected with the special prevalence. Moreover,
careful study of the age incidence and topographical distribution both of the persons attacked and
the purchasers of fried fish at the particular shop, yielded strong evidence in support of the hypothesis
of fish infection, evidence which is further strengthened by the fact that there were numerous instances
among families where a single person bought suspected fish and was alone attacked, whilst among
families sharing fish multiple cases occurred.
Dr. Thomas points out that during a period of three weeks 18,000 dinners and suppers were
served from the fish shop and that only 74 cases of typhoid fever developed. The presumption that
all the fish supplied during the three weeks' period fell under suspicion has not, of course, at any time
been raised. My report dealt fully with the question of the particular consignment or consignments
of fish, if any, at fault, and analysis of the available evidence makes it clear that it was only the
"cheaper portions of fried fish sold to the early evening customers on a particular evening in
August " which could be held to fall under suspicion (see Chapter XXXIII.).
Incidentally, evidence was obtained which raised some presumption that the infected fish was
distributed not only in Finsbury but also in two other boroughs. The dates of onset of illness pointed
to the delivery in London of the infected consignment of fish on Thursday, 17th August, or Friday,
18th August. It is a matter of interest to note that the deliveries of fish in London on these dates
were in some instances from unusual sources owing to dislocation of traffic caused by a strike.
Thus the Times of 22nd August, in commenting upon the unusual sight presented by thirteen North
Sea steam trawlers at Billingsgate on the preceding day, notes that, "owing to the strike, trawler
owners on the coast found it impossible to dispose of their boat catches at the end of the preceding
week."
In the course of the enquiry into the Finsbury outbreak it was ascertained that at least 20
sufferers from typhoid fever in other parts of London in September had been infected whilst staying
at Ramsgate in the latter part of August. These persons were ascertained by Dr. Dundas, medical
officer of health of Ramsgate, to have in nearly every instance partaken of cockles, usually in a raw
state. In none of the London outbreaks which were presumably attributable to fish had any sufferer
partaken of cockles at Ramsgate.
The occurrence of the Finsbury outbreak attributed to infected fish adds to the number of
prevalences of typhoid fever in London which have been held to be due to this cause. Sir Shirley
Murphy, in his annual report for 1910 thus summarised the facts with regard to these prevalences :—
"In the year 1900 three localised prevalences of typhoid fever occurred, and one of these prevalences
(in Southwark), involving, as it did, some 120 cases of typhoid fever, developing within a
period of five weeks, was on a sufficiently large scale to allow statistical inferences to be drawn. Dr.
Hamer was, in fact, able to adduce a considerable body of evidence in favour of his thesis that the
Southwark prevalence was due to consumption of infected fish, and he raised the question as to whether
the other two prevalences (in Lambeth and in Kensal Town) might not have had a similar origin.
In 1903 the same cause was assigned by him, as result of enquiry, for small prevalences of typhoid
fever in Holborn and in Southwark, and in 1906 there was some evidence pointing in a similar
direction. In 1908 fish again fell under suspicion in Bethnal Green and Shoreditch.