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slightly less marked in area iii., and the outbreak in this area also presented the peculiarity as
compared with those in i. and ii., that it was apparently traceable not to fried fish, but to fish
purchased in the wet condition and cooked at home.
On turning now to the prevalences of November and December, 1903 (charts iv., v., and vi.),
it will be found (allowance being made for the smaller number of cases) tbat chart v. (Holborn)
yields distinct suggestion of relationship, so far as age-incidence and multiple cases are concerned,
to charts i., ii. and iii.; in chart iv. (Southwark) the resemblance is less striking, the percentage
of black squares being high, but the figures dealt with are still smaller than in v., and the area to
which chart iv. relates is a small one—as a matter of fact the outbreak of November, 1903, extended
somewhat beyond the area dealt with in the chart, and if the outlying cases be included, the percentage
of cases at ages 0 to 2 and 26 onwards to other cases becomes appreciably lowered. In
chart vi. there are, as already noted, only three cases in December, 1903, and no conspicuous
resemblance to charts i., ii., and iii. can, under the circumstances, be looked for.
The history of consumption of fish obtained from a particular shop, at about the time when
infection must have been contracted in the case of the three patients in area vi., has already been
referred to (See page 6), and it has been noted that a case infected some weeks previously to these
three was held by the patient's friends to have been caused by eating fried fish obtained from the
same shop one fortnight prior to attack by the disease.* In the fried fish enteric fever prevalences
of 1900 (i., ii. and iii.) the districts involved were not attacked quite simultaneously ; and again
in 1903, area iv. was attacked about three weeks before areas v. and vi. Having in view these
instances of want of simultaneity of infection, the possibility presents itself that the same retail
shop may have distributed infection at the close of 1903 on two distinct occasions separated by an
interval (See chart for area vi. in October and December, 1903). There then arises the further
possibility that persons living in the area vi. and in other areas surrounding implicated fried fish
shops may have from time to time been infected during recent years from those shops. Examination
of notifications (1896—1903) for the areas in which the six implicated shops lie shows—
(a) That in each instance the area has during these eight years suffered unduly
from enteric fever, London as a whole being taken as the standard of incidence.
(b) That in each instance the percentage of cases at ages 3 to 25 inclusive to other
cases is unduly high compared with London as a standard.
(c) That in area ii.t there were, at the close of 1896 and 1899, two small outbreaks,
the appearance of which on the chart suggests their possible affinity to that of 1900 ; in
area iii. the small outbreak at the close of 1899 is also noteworthy ; in the case of area
iv. attention may be directed to the appearance of the chart at the beginning of 1900 ;
and charts v. and vi. yield indications of a somewhat similar kind, the former at the end
of 1898, and the latter at the end of 1899.
The suggestion now presented itself that the characteristics of the fried fish outbreaks
occurring in certain areas in 1900 might perhaps in other areas be more nearly approached during
1899 and 1900 (years when enteric fever was unwontedly prevalent in London) than in other years,
and this consideration, has led to examination of areas in which there was exceptional prevalence
of enteric fever in those two years. Under this head reference may be made to charts
vii., viii., xiv., xv., xvi., and xvii. In each of these areas (with an exception to be noted as regards
viii.) it will be found that—
(1) The proportion of cases at the ages 0 to 2 and 26 onwards to the remaining cases
is below the normal 50 per cent. In area xvii. it is 46 per cent., in area xvi. 37 per cent.,
in area vii. 44 per cent., in area xv. 36 per cent., and in area xiv. it is only 22 per cent;
in area vii., on the other hand, it is nearly 74 per cent.
(2) That outbreaks presenting suggestion of affinity to those of 1900 in areas i. and ii.
have from time to time occurred.
In area vii. (Kentish Town) there were such outbreaks in 1896, 1899, 1900, and
1902.
In area viii. (Starch Green) similar outbreaks occurred in 1899 and 1900.
In area xiv. (Hackney Wick) there are several outbreaks presenting some suggestion
of having similar affinity, the most notable of these being one in 1901 ; it will also be
seen that an outbreak having somewhat similar features occurred in this area in September,
1903, shortly before the occurrence of the outbreaks of that year in areas iv., v.
and vi.
In area xv. (Hackney Wick) outbreaks also raising suspicion occurred at the close
of 1899 and 1900, and in this area the occurrence of a group of cases at the close of 1903
is also noteworthy.
In area xvi. (Millwall) the years 1896 and 1897 present a small percentage of black
squares, and the outbreaks at the close of 1898, 1899 and 1900 are noteworthy.
In area xvii. (Cubitt Town) the year 1896 is suggestive, less so the years 1899
and 1902, while the group of cases in the two last months of 1903 is again striking. (See
pages 5 and 7.)
Chart xiii. (Garratt-lane) relates to an area (See paragraph commencing " Group (iv.)
included " on p. 7.) to which attention was directed owing to multiple house attacks occurring in
* My attention was in the first instance directed to this case by Dr. Millson, and I found on visiting the house that the circumstances
which have been already referred to had particularly impressed themselves upon the minds of the inmates, who attached
importance to the facts that the sufferer alone had partaken of the fifh, and that he had complained at the time of eating it that it was
not of good quality. As already noted, a fifth case was apparently associated with this shop.
t The shop in area ii. was carried on in the same name as shops situated at the centre of two areas, ix. and x. Each of these last
named areas presented cases of enteric fever at the time of the 1903 prevalences in areas iv.. v. and vi., and area x. presents a somewhat
suggestive prevalence at the close of 1902, while the chart for area ix., at the close of 1899 and 1900, raises some suspicion of being
affected by the cause operative in the case of area ii., certainly in the latter and possibly in the earlier of those two years.