London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1900

[Report of the Medical Officer of Health for London County Council]

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4th to 24th there were seven cases to which particular attention may be directed in this connection.
Five of these cases have been placed in column 1, as distinguished from the cases in column
3, of the diagram already referred to. In the remaining two cases infection was apparently traceable
to previous cases which had occurred in the area; these two are placed in column 2. Of the former
group of five cases one proved not to be a case of enteric fever. There remain four cases in column 1.
Two of these patients were certainly, and a third probably, living away from the area at the date
at which, having regard to the course of their disease, they were presumably infected. The fourth
patient lived on the extreme boundary of the infected area. The question arises whether these cases
should not be excluded from consideration in discussing the special cause of the outbreak. If
they be so excluded, the numbers giving the intensity of incidence of enteric fever, upon equal
elements of area, for the four portions of the affected area are 329, 84, 11, and 6, showing, in an
even more striking manner than was the case before, the diminution in the intensity of incidence
noticeable on proceeding outwards from the fried fish shop as a centre. Two cases occurred in
houses altogether outside the quarter-mile radius to which reference may here be made. In one
of these the girl attacked worked in the area, and her case has been referred to the place at which
she worked, and she is thus included in the above summary. The facts concerning her are given
in the appended notes, case 47. A second case is that of a girl, case 22 in the appended notes,
who worked at premises only just outside the affected area.*
The consumers of the fish of a particular vendor in each area have been indicated by red
figures. Two of the cases in column 1, Southwark, Nos. 3 and 17, might perhaps more properly
have been indicated in black, but all the cases in column 3, with the possible exception of
six, undoubtedly ate fish from the particular fried fish shop at a time corresponding
to the date of infection. As regards these six possible exceptions, in four there is
a history of uncooked fish, obtained from a shop next door but one to the fried fish
shop and in the same ownership, having been consumed, and two of the four may also have
eaten fried fish, but this cannot be stated with certainty. These cases are marked thus—23†, 63†,
70† and 105† As regards the other two cases—39‡ and 71‡—there is some likelihood that they
ate fried fish from the particular shop, though the history is on the whole less conclusive as regards
the former than as regards the latter case. Further, as regards case 71, it may be noted that the
girl had been staying away from home for a few days at a time corresponding with a part of the
period which may be looked upon as the probable period of infection. On the whole, therefore,
after making a not unreasonable allowance for the sporadic cases which might have been expected
to occur in an area of the size and character of the affected area, there is high probability that all
the rest of the cases ate fried fish (in four cases fish from the same source, but not fried) at a time
which must be regarded as corresponding with the date of infection.
The particulars as to individual cases given in the appended notes show the extent to which
wet fish, dry fish, fried fish, and shell fish from this shop were consumed by persons attacked.
They may be summarised as follows so far as cases given in the third column (which were attacked
between September 4th and 24th) are concerned—
Fried fish.—All, with the possible exception of four, who bought their fish uncooked,
(but from the same source as that from which the fried fish shop was supplied) and two
others discussed above, in the case of whom the history is not conclusive.
Uncooked fish.—In only 34 of the 98 cases was there a history of purchasing
uncooked fish. Fish in this form was said by several of those questioned to be beyond
their means. To these 34 cases should perhaps be added a few others who may have
exceptionally purchased a haddock or a bloater from the particular shop. It is quite
clear, however, that uncooked fish from this shop was not eaten, during the period when
infection must have occurred, by more than half the persons attacked.
Shell fish.—In 65 cases shell fish or shrimps had been consumed. In several of
these it was said to be a common thing to buy shell fish (usually winkles) or shrimps for
tea on Sunday. In the majority it was only exceptionally that such luxuries were purchased.
Apart from periwinkles very little shell fish was eaten in the area. Occasionally
mussels were consumed; in only one instance was mention made of oysters.
The question that now arises is what proportion of the whole population of the affected
area was consuming fried fish obtained from the particular shop. This question has been made
the subject of inquiry, the result of which it is necessarv to state. Before doing so, however, it
may be well to briefly indicate the distribution of fish shops (fried fish shops and others) in the
neighbourhood of the affected area.
This will be seen on reference to the map, on which fried fish shops and ordinary fishmongers'
shops existing in the locality are indicated. The particular fried fish shop referred
to above, and indicated in the appended notes as Mr. X's shop, is at the centre of the circle; next
door but one to it is an ordinary fishmonger's shop, also in the occupation of Mr. X. It will be
seen that the latter shop, which is practically at the centre of the circle, has no other fishmonger's
shop within some distance of it. -Tust at the circumference of the circle, which is approximately
a quarter of a mile—i.e., 4'40 yards—from this shop, are four fishmongers' shops which are indicated
on the map. The fried fish shop, on the other hand, has other fried fish shops within a much
smaller distance of it. At the nearest of these, which is situated a little to the north-west of the
centre of the circle, a similar class of business to that at Mr. X's shop is carried on, but on a
considerably smaller scale. At the shop situated to the east of Mr. X's shop a large business
*A third case was heard of in the course of the inquiry, which might perhaps have properly been also
inciuded in the above summary. It was that of a man living at some distance from the area, who was employed
for some days, at about, the time when he must have been infected, on premises in the near neighbourhood of
the fried fish shop; he may have bought fried fish at the particular shop in the affected area, as he was often in
the company of a young man who was certainly in the habit of doing so (see the case indicated by the red dagger
adjoining case 39, and referred to in the appended notes), but the case was a fatal one, and the question could
not be determined.