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Of the total thirteen cases, five were adults, and eight were children; eleven resided in St.
Pancras, and two in Holborn.
It was ascertained quite early in the investigation that the food responsible for the outbreak
was pease pudding. This had been made on Saturday, the 7th October, the procedure being as
follows:—About 4.30 p.m. four pounds of dried split peas in a canvas bag were placed in an
enamelled iron saucepan, containing boiling water, to which a little bicarbonate of soda had been
added. After coming to the boil they were allowed to "simmer" for three hours, were then emptied
into a glazed earthenware vessel, some salt was added, and they were then beaten up with a wooden
spatula, about a pint of the water in which the peas had been cooked being added. The process was
completed about 7.30 p.m., the finished product weighing about seven or eight pounds.
The earthenware vessel containing the pease pudding was kept near a gas stove in a room
behind the shop, and at intervals, during the evening, a little boiling water was added to keep the
pudding warm and moist. The conditions were therefore ideal for bacterial multiplication.
Portions of about five ounces were sold for a penny, each portion being placed in a piece of
greaseproof paper and then wrapped in newspaper. It was thought that about eighteen to twenty
customers were served with the pudding during Saturday evening as, approximately, two pounds
remained unsold.
In the thirteen notified cases the pudding was stated to have been purchased or eaten between
7.45 and 10 p.m.. and in practically all the cases the onset of symptoms occurred in the early hours
of Sunday morning.
The clinical signs and symptoms, which were more or less marked according to the severity
of the attack, included vomiting, abdominal pain, diarrhœa, with passing of blood and mucous,
rapid pulse, rise of temperature and cyanosis of lips and extremities.
The two fatal cases were boys of 11 and 13 years of age, one died at 7 p.m., the other at 9 p.m.
on Sunday, that is, within a period of twenty-four hours of having eaten the pudding. In each of
these cases only one pennyworth had been purchased, and each boy had given a portion of this to
another child, both of whom were subsequently ill.
An indication of the severity of the infection may also be gained from the fact that one case, a
woman of fifty-four years of age, who had eaten only three tcaspoonfuls of the pudding, and thinking
it tasted "musty," threw the remainder in the fire, was taken acutely ill on Sunday morning, and
obtained medical advice.
The onset of the symptoms was sufficiently rapid to suggest the possibility of chemical (inorganic)
poisoning, although the rise of temperature pointed to a bacterial infection. Both chemical
and bacteriological investigations were therefore made.
The report of the Analyst stated that uo chemical poison could be found either in the dried
peas, pease pudding, salt or soda, nor in the vessels in which the pudding had been prepared or
stored.
The report of the bacteriologist was as follows:—
(1) Dried Peas. B. Coli, Streptococci, B. Welcliii, and a few colonies B. Fæcalis
Alkaligenes.
(2) Pease Pudding. An abundant growth of B. Coli, Streptococci, B. Welchii, a marked
growth of B. Fæcalis Alkaligenes and gram negative bacilli which had the reactions
of B. Dysenterise. This organism agglutinated well with an Anti-Sonne dysentery
serum.
From material obtained from the two fatal cases and also from the patient admitted to
University College Hospital, dysentery bacilli of the Sonne type were isolated.
As dysentery bacilli were not found in the sample of dried peas, but were present in the pease
pudding, it appeared to be probable that the infection had been conveyed to the pudding after it was
made. It was, however, feasible, owing to the number and character of the organisms present in the
dried peas, that dysentery bacilli might also be present, although they had not been isolated from