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of the total population of the borough. Thus a population of between two and three thousand persons
living in these six streets supplied as many cases during the year 1908 as did the whole of the rest
of Shoreditch, with a population of some 113,000 persons. It should be noted, moreover, that the
borough of Shoreditch is largely occupied by poor persons, and the character of the population of
the specially affected area does not differ so markedly from that of the rest of the borough as to
afford any adequate explanation of this very excessive incidence of enteric fever upon the implicated
area.
Dr. Bryett has demonstrated (see his Annual Report) certain curious relationships between
the persons who were attacked in the special area—some of the children had played with other children
previously attacked—in some instances sufferers were actually related to one another by blood or
marriage—some of those attacked had shopped in the special area, or had marketed in the neighbourhood,
or had visited there. These relationships, however, while they testify to the fact that the
population specially attacked had many circumstances in common, cannot be regarded as finally
demonstrating that direct case to case infection occurred in all instances. It might, indeed, be argued
that relationships of a like sort would, provided close inquiry were made, be discovered in any area of
similar character to the Shoreditch area, which chanced to be attacked to the same extent by
enteric fever. In fact, an exclusive hypothesis of direct personal contact cannot be held to be
sufficient explanation of the heavy incidence of the disease upon this area, unless it be assumed that
the enteric fever prevailing therein manifested a special ability to spread by contact from person to
person, either because of some peculiarity of the enteric fever germ of that area, or because the
circumstances of the area itself were wholly exceptional. Dr. Bryett has referred to discovery of a
number of unrecognised cases of the disease in the area, but, unless it be assumed that the enteric
fever of the area was peculiar in its tendency to show itself in a masked form, this existence of
unrecognised cases will not explain the remarkable incidence of the fever upon this area. Dr. Bryett
made personal inquiry concerning all the cases of notified or suspected illness, and the fact that so
many unrecognised cases were discovered may be held to testify to the thoroughness of his investigations
rather than to any peculiarity of the disease as exhibited in Shoreditch. A further point
against assuming that in Shoreditch personal contact played a predominant role is that in almost
all instances the cases were removed, immediately they were discovered, to the Metropolitan
Asylums Board's Hospitals.
On the other hand, it might reasonably be contended that the relationships referred to, those of
playmates, of marketing, visiting, etc., might all find explanation, apart altogether from the question
of personal contact, on the hypothesis that the enteric fever in the area was due to an infected food
supply. I discussed the matter on numerous occasions with Dr. Bryett and he made inquiries which
led him, as did my own investigations in Bethnal Green, to the conclusion that a shell-fish hypothesis
(and only mussels really came into question) would not explain the outbreak. Dr. Bryett also made
inquiries as to fried-fish shops, again with a negative result. It seems, however, that in Shoreditch, and
the same thing is true of Bethnal Green, fish and shell-fish are at certain times of the year habitually
purchased from costermongers, who have barrows which either stand at a particular street corner
or in some other prominent position, or else are wheeled about on a more or less defined "round"
from street to street.
As regards the Shoreditch area it has transpired that several such itinerant vendors of fish and
shell-fish lived, during 1908, in houses in the six affected streets. Within the area is a common lodginghouse,
and the information obtained with regard to the street traders was obtained in the first instance
from lodgers in this house, and inquiries were then made into the particular facts ascertained by Mr.
Jury, the chief inspector of common lodging-houses, and by Mr. Rowe and Mr. Shapley, inspectors
in the public health department. Briefly it may be stated that in the household of a particular
costermonger, whose home was situated just about the centre of the affected area, several cases of
enteric fever occurred in the early months of 1908 (see Dr. Bryett's report—cases 7-10). The man
himself died "from the effects of a fall" on March 20th. Dr. Bryett notes that "the stall was not
kept on after his death" ; but clearly the wants of his customers who lived in the immediate neighbourhood,
were likely to be supplied by other vendors of fish and shell-fish and possibly by other
costermongers, of whom there were two or three close by. A second costermonger carrying on a trade
similar to that of the man who died, lived about a hundred yards away. This man sold "dabs" and
shell-fish throughout the year until August, 1908, but not after that. A third costermonger, living
in the same street as the man last named, had sold fish repeatedly during 1908, but he told me he did
not "work the streets" which the first named costermonger had worked, nor did he know who did
so after the death of the first-named costermonger. This third costermonger explained that, while
most of the costermongers had regular rounds, if any costermonger had doubtful fish or shell-fish to
dispose of, he would not be likely to sell them on his regular round, but elsewhere. He further
entered into details as to the rounds worked by himself and by other costermongers in Bethnal Green.
Mr. Rowe, moreover, obtained particulars concerning a number of the costermongers working" the
Shoreditch and Bethnal Green streets, but it was not found possible to determine that any one
individual costermonger had supplied fish to consumers in the areas affected in Shoreditch and
Bethnal Green. In view, however, of the facts elicited it is necessary to have regard to the.possibility
that infected fish, sold on some three or four separate occasions by a costermonger or costermongers,
may explain the excessive incidence in 1908 of enteric fever upon these special areas in Bethnal Green
and in Shoreditch.
Such a hypothesis is capable of explaining the incidence of the disease upon the populations
attacked. Moreover, so far as could be ascertained, no other food than cheap fish could by any possibility