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Of these the first objection in itself might have been regarded as a fatal one, had it not been
for the recollection of certain experiences in connection with cholera. In the report of the
medical officer of health of the County of London on Cholera in London in 1893 (appendix II.,
annual report for 1893) there is noted the fact that two persons suspected to be suffering from
cholera in Clerkenwell in that year had consumed fried fish said to have come from Grimsby
(cases 8 and 9). Again, case 1, "the Westminster case," which proved, on bacteriological
examination, to be a case of Asiatic cholera, had also a history of having eaten fried fish—for
supper three days before the date of attack. In cases 8 and 9 the bacteriological examination
gave a negative result, but these cases were included by Dr. Barry in his report to the Local
Government Board as cholera cases; they seem to have been so included mainly on account of the
existence of the thread of connection between them and Grimsby, afforded by the history of their
having eaten fish from that port. With these cases in view it did not appear justifiable to
altogether dismiss the fried fish hypothesis from consideration on mere a priori grounds.
Moreover, a little observation made it clear that the ages of consumers of fish would have
to be made the subject of study. Persons entering and leaving the fried-fish shop were seen to be
for the most part young persons; inquiries made on this point as to fried-fish eaters in other
parts of London corroborated this impression, and it was clearly, therefore, desirable to pursue the
matter further and obtain precise information on this head.
On September 27th inquiry was made as to the sources from which the particular fish shop
was supplied. The origin of most of the fish could be traced, but certain supplies were purchased
concerning which detailed information was not available. On the same day the suspicion entertained
concerning fried fish, together with the information obtained with regard to sources of
supply, was communicated both to Dr. Parkes and Dr. Priestley.
From this date onwards much time was spent in studying the facts as to the Southwark
cases, and this necessitated, since the large majority of the patients were removed to hospital,
a number of visits to hospitals of the Metropolitan Asylums Board ; this work was much facilitated
by the cordial aid given by the medical superintendents and assistant medical officers of these
institutions. While this work proceeded careful observation was kept by the Council's inspectors
under the direction of Mr. Jury, the chief inspector of common lodging-houses, upon the fried
fish shop, and, for purposes of comparison, upon several other fried fish shops, and as the result
of these inquiries it became clear that the ages specially attacked in the Southwark outbreak
were the same as those observed by the inspectors to be represented in large proportion among
the persons consuming fried fish. Age incidence, in place of being a difficulty, was, in so far as
importance could be attached to it in the face of other difficulties, suggestive of fried fish as the
cause of the outbreak. It was now clear that the fish hypothesis required to be carefully examined
from the statistical side, and this was accordingly done.
The particulars gradually accumulated in Southwark showed more and more clearly that
while the question as to whether the observed relation between consumption of fried fish and
enteric fever was one of cause and effect or of mere chance coincidence was a complicated one,
there was good reason for deciding that the relation was one of cause and effect. It became
important therefore to study the facts in regard to the outbreaks which had occurred practically
simultaneously in other parts of London, in the light of the Southwark experience.
In Lambeth Dr. Priestley had formed the opinion that the disease had been spread in the
main by infection transmitted in the course of wringing and mangling operations. He caused
inquiries to be made, however, with regard to fish, and pointed out certain difficulties in the
way of accepting a fried-fish hypothesis as explanation of the Lambeth outbreak. These difficulties
required to be carefully examined. In the outcome it appeared that the Lambeth case, considered
by itself, did not do more than raise a suspicion, but it assumed larger importance when, it was
borne in mind that its occurrence nearly coincided in point of time with the Southwark outbreak.
Lastly, the question of Kensal Town had to be considered. Dr. Parkes had given directions for
the facts to be ascertained, and Mr. Metzler, the sanitary inspector, readily gave me all the
assistance I desired in this connection. The chief inspector of Kensington, Mr. Pettit, moreover,
obtained for me particulars concerning cases occurring in North Kensington, in the near
neighbourhood of Kensal Town. The facts as to Kensal Town were found to be in marked
contrast in several respects with those of the other two prevalences; in themselves they afford
little or no support to the hypothesis of distribution by fish, but they are perhaps deserving of
study in connection with the other outbreaks.
I therefore proceed to give a brief resume of the particulars ascertained in each of the three
districts.
Southwark.
The locality affected in St. George-the-Martyr, Southwark, was of very limited extent,
inasmuch as with three exceptions all the cases belonging to that parish, in which symptoms of
enteric fever commenced between September 4th and September 24th, were notified from houses
within an area of considerably less than a quarter of a square mile. A few cases occurred at
about the same time in an adjoining portion of the parish of St. Saviour, Southwark, and it was
found that these cases and the St. George-the-Martyr cases (with the exception of the three
already referred to) could all be included within a circle having a radius of a quarter of a
mile. The precise position of the limiting circle was determined by considerations to be afterwards
specified; it will be sufficient here to say that the area as defined on the accompanying map
includes all the cases above referred to, with the exceptions noted. The circle was found to cover,
at its south-eastern border, a small strip of land in the parish of Newington. The area thus
defined contains a group of large blocks of tenement dwellings six storeys high, with gloomy
courtyards, dark staircases, and other sanitary defects; these dwellings afford accommodation