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(а) The Holborn outbreak.—This outbreak has been made the subject of special report by
Dr. Bond, and is referred to by Dr. Allan in his monthly report for December, dealing with
statistics relating to the fourth quarter of the year 1903. A statement of particulars of the
cases is appended (See Appendix I.); briefly the facts may be analysed as follows. Between
November 21st and December 7th, 17 persons commenced to sicken with enteric fever within,
an area, partly in Holborn and partly in Westminster, bounded by a circle of a quarter mile
radius and having at its centre a fried fish shop in the latter district. One of the patients denied
having partaken of fried fish, the date of attack in this person was consistent with the case
being regarded as secondary to a previous case in the same house; in another instance no history
of having eaten fried fish was obtained, but this case was apparently imported into the area, and
infection was presumably contracted in North London. Of the remaining 15 cases, 10 had, at
about the time when infection presumably occurred, eaten fried fish obtained from the shop taken as
the centre of the area; another probably did so also, and three more ate fried fish which was
possibly obtained from this shop. The remaining patient had at about the time when infection
must have occurred eaten fried fish purchased at a shop situated north-east of the centre of the
area, and four o'ther patients (included in the 15) had been supplied with fish from this second shop
(these four included the three whose having been supplied from the first shop was not a
matter of certainty). In view of these occurrences the suggestion presented itself that there
had been community of origin of the fish sold at the two shops; inquiry was made
as to this, but while the possibility was not negatived the information obtained did
not demonstrate a common source of supply. Both fishmongers, at the time when infective
material must be assumed to have been introduced into Holborn and Westminster, had bought
plaice at Billingsgate, and both had in the main been supplied with this fish from a particular
port, but nothing beyond this was ascertainable so far as community of original source was
concerned. It was definitely stated by both the vendors that there had been no intercommunication
between their retail establishments, and though both on occasion had been supplied with fish
from Grimsby sent direct to King's-cross, the middlemen concerned in supplying the fish did
not, so far as could be learned, belong to the same firm, nor were their businesses in any ascertainable
way related to one another.
(б) The Southwark outbreak.—Particulars as to individual cases constituting this localised
prevalence of the disease are appended (See Appendix II.). These cases occurred in an area surrounding
a small fried fish shop, and for the most part the invaded houses were within a few
hundred yards of the shop. In an area bounded by a circle of a quarter mile radius with this shop
as centre, there occurred between October 17th and 31st 14 cases, in nine of which there was a
history that the patient had in all probability eaten fried fish obtained at this shop, at about the
date when he or she must have been infected, while four others are quite likely to have done so.*
The incidence upon consumers of fried fish from a particular shop in this small outbreak was
thus very striking, and further, the age-incidence of the disease was noteworthy, young persons
being specially affected.
It has been mentioned that most of the sufferers (12 out of 14, in fact) lived in houses
supplied by the Southwark and Vauxhall Water Company. It has also been pointed out that
the central portion of the area, in which the majority of the cases occurred, was found to be
supplied exclusively by that company. The possibility of pollution of a local main presents
itself, but no reasons for supposing such pollution had occurred were forthcoming. The circumstances
as regards water supply generally, however, will be further considered in connection with
the behaviour of enteric fever in surrounding parts of London at the close of the year 1903.
Inquiries made as to milk, shellfish, ice-cream and watercress yielded negative results. The
question of use of a swimming bath was also considered, but in only five of the 14 cases was there
a history of having visited this bath, and this proportion was not larger than might a priori
have been anticipated, having in view the ages of those attacked; again, if pollution of the water
of the bath had been responsible for the outbreak, it may be assumed that the disease would have
extended over the entire area inhabited by persons who used the swimming bath referred to, and
would not have been limited, as was actually the case, to a particular portion of that area. Having
regard to all these facts, and considered in the light of the history of enteric fever prevalences in
London in 1900, the case against fish in this Southwark outbreak must be regarded as a very
strong one.
(c) The behaviour of enteric fever in London at the close of the year 1903.—When it was
ascertained that localised outbreaks of enteric fever occurring in November in Holborn and Southwark
were in all probability attributable to the consumption of fried fish, attention was naturally
directed to the behaviour of the disease in London as a whole at this time. It was found that the
number of weekly notifications of enteric fever, having attained a maximum in the 40th week of
the year (the week ending 10th October), had fallen sharply in the 41st week, and again slightly
in the 42nd week; in the 43rd and 44th weeks there was a small rise, the notifications in the
45th and 46th weeks were, however, somewhat smaller in number, and then in the 47th and 48th
weeks a notably increased prevalence declared itself; after this the notifications fell off again as
the end of the year approached. The small rise referred to above in the 43rd and 44th weeks
coincided in point of time with the Southwark outbreak, and may thus be thought of as being
accounted for by that outbreak ; the considerable rise in the 47th and 48th weeks corresponded
* In one instance only was the information to the effect that fried fish from this shop had not been consumed; the sufferer, a
lad of 12, stated that some days before his illness commenced he bought fried potatoes at a fried fish shop (not the shop in question), but
he denied ever having eaten fried fish. It may be noted that the fried fish shop in this instance supplied far fewer persons with fish
than did the shop in Southwark, referred to in footnote on p. 3. The percentage of persons obtaining fried fish from the latter shop
being 42 (See footnote on preceding page), it maybe taken for granted that the corresponding figure for the shop now in question
would not exceed 15 or at most 20 per cent.